Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap.

BACKGROUND: In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery1, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps2. We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions. MATERIALS AND METHODS: In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively. RESULTS: Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission. CONCLUSION: Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.

Breast reconstruction using a latissimus dorsi flap after mastectomy.

INTRODUCTION: The latissimus dorsi (LD) myocutaneous flap has long been regarded as the second choice flap for autologous breast reconstruction following a mastectomy in our department. Despite uncertainty about donor-site morbidity, it is regarded as a relatively safe procedure; moreover, in contrast to our first choice, the deep inferior epigastric perforator flap, no microsurgical expertise is needed. METHODS: This is a systematic review of patient files for all LD breast reconstructions performed in the 2004-2013 period, at Rigshospitalet, Copenhagen, Denmark. RESULTS: A total of 135 unilateral LD breast reconstructions were performed in 126 women during the ten-year period. The median age of the women was 48.5 years, and they mainly had secondary reconstruction (90%). The average time to removal of the last drain was 6.3 days, and the average time to discharge was 6.9 days. A total of 13 patients (10%) had local complications and were re-operated within the first 30 days. We observed one flap loss and only one systemic complication; a urinary tract infection. In all, 38 patients (28%) received antibiotic treatment after the operations and 27 (20%) developed a seroma at the donor site on the back. Patients who developed seroma were four times as likely as those who did not to be readmitted for antibiotic treatment. CONCLUSIONS: LD breast reconstruction remains a safe choice for autologous breast reconstruction. Prevention of donor-site seroma as well as improvement of the clinical pathway and post-operative regimen could be future focus-points for this procedure. FUNDING: The review was performed as part of the pre-graduate research year project, "Donor-site morbidity after m. latissimus dorsi reconstruction", funded by Concordiafonden. TRIAL REGISTRATION: not relevant.

[Breast reconstruction with m. latissimus dorsi--status and perspectives]. / Brystrekonstruktion med m. latissimus dorsi er et godt valg hos kvinder med brystkræft.

Breast reconstruction using autologous tissue is commonly used in breast cancer patients who have received radiation therapy. The use of a latissimus dorsi flap is a safe and viable alternative to the use of an abdominal flap. The cosmetic results are excellent but there is need for a better understanding of the donor-site morbidity in regard to potential loss of shoulder function. We believe that it is possible to improve the procedure through optimized surgical technique in combination with the implementation and the benefits of fast-track surgery.