Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Tissue Expander-based Breast Reconstruction.

Background: Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center. Methods: All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days. Results: There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, P < 0.001), be discharged by day 1 (96.5% versus 70.2%, P < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, P < 0.001). Seroma rates (17.4% versus 3.5%, P < 0.001) and hematoma incidence (4.5% versus 0%, P = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (ß=-60.7, P < 0.001) and a shorter inpatient duration by 0.4 days (ß =-0.4, P < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (ß=-30.9, P = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, P = 0.009). Conclusions: ERAS protocols significantly reduce opioid use and hospital stay after TEBR.

Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction.

Background: Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods: Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results: In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions: Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction.

Background: Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods: The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results: The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant. Conclusion: Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Anaphylactic Reaction to Lymphazurin 1% during Breast Reconstruction Surgery: An Uncommon but Serious Complication.

Lymphazurin 1% (isosulfan blue dye) is the most frequently used blue dye in the United States, and it is commonly used for sentinel node biopsy in breast cancer patients. Although cases of allergic reaction to lymphazurin have been reported in the general surgery literature, to our knowledge, no cases of an adverse reaction to isosulfan blue have been reported in the plastic surgery literature. We describe a case of an intraoperative biphasic anaphylactic reaction to isosulfan blue in a female patient undergoing bilateral mastectomy and immediate bilateral DIEP breast reconstruction. The severity of her anaphylactic reaction required that we stop flap dissection and abort the reconstruction. Although an allergic reaction is uncommon, recognizing the signs of an acute hypersensitivity reaction is critical to good outcomes in these situations. Given the volume of combined breast oncologic and breast reconstruction surgeries and the increasing number of vascularized lymph node transfer and lymphovenous anastomosis performed annually, it is essential for the plastic surgeon to be cognizant of this rare hypersensitivity reaction.

Comparison of immediate postoperative pain in implant-based breast reconstructions.

BACKGROUND: Implant-based techniques represent the most common form of breast reconstruction. However, substantial postoperative pain has been associated with implant-based breast reconstruction. OBJECTIVE: The objective of this study is to evaluate immediate postoperative pain in implant-based breast reconstruction. METHODS: We reviewed 378 patients who underwent implant-based reconstruction between January 2004 and December 2012. Each patient's visual analog scale (VAS) score, pain medication, and patient-controlled analgesia (PCA) attempts were used to assess in-hospital postoperative pain. We evaluated timing of reconstruction post mastectomy, tissue expander (TE) designed fill volume, TE initial fill volume, and single-stage immediate implant (II) versus TE reconstruction. RESULTS: No significant differences in pain parameters were noted between the immediate and delayed postmastectomy reconstruction cohorts. TEs with larger (>300 cc) designed volumes required significantly more narcotic use (p = 0.02) and PCA attempts (p < 0.01). Narcotic use was higher in the larger (>250-cc) TE initial fill group starting on postoperative day 2, but overall differences in VAS score and PCA attempts were not significant. Morphine equivalence (p < 0.01) and non-opioid oral analgesic use (average p = 0.03) of the TE cohort were significantly higher than those of the II cohort. CONCLUSION: Patients undergoing TE-based implant reconstruction show greater analgesic use than those with single-stage II-based reconstruction. This may indicate a higher immediate postoperative pain in TE procedures than in II procedures. Furthermore, higher initial fill and designed volume of TE require more morphine equivalence postoperatively. These findings may warrant further preoperative discussion for better pain management and patient satisfaction.

Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions.

BACKGROUND: Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction. METHODS: Patients undergoing primary implant-based (n = 1038) or flap-based (n = 837) reconstructions from 2004 to 2012 at the University of California, Los Angeles, were evaluated. Postoperative pain was measured using the visual analogue scale, total narcotic use, and number of patient-controlled analgesia attempts. Narcotic dosage was standardized to morphine equivalents per kilogram. The authors modeled postoperative narcotic use, patient-controlled analgesia attempts, and visual analogue scale scores over time using spline graphs for comparison between the two reconstruction methods. RESULTS: Both total narcotic use and patient-controlled analgesia attempts were higher in the implant-based group throughout the immediate postoperative period. Implant-based reconstruction patients had significantly higher visual analogue scale scores (p < 0.0001) and total narcotic use (p < 0.0001) through postoperative day 3 compared with autologous tissue-based reconstruction patients. When controlling for reconstruction method, bilateral procedures were more painful (visual analogue scale score and patient-controlled analgesia attempts, both p < 0.001). When controlling for laterality, unilateral implant-based and autologous reconstructions had comparable visual analogue scale scores (p = 0.38) and patient-controlled analgesia attempts. However, unilateral implant-based procedures required more narcotic use than unilateral autologous tissue-based procedures (p = 0.0012). CONCLUSION: Although commonly perceived as a less distressing operation, implant-based breast reconstruction may be more painful during the immediate postoperative hospitalization than abdominally based free tissue transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction.

BACKGROUND: The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. METHODS: All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. RESULTS: A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. CONCLUSIONS: Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Recent trends in resident career choices after plastic surgery training.

The purpose of this study is to determine the initial career choice of plastic surgery residents after completion of training during the last five years and to identify any factors that may influence choice of career path. Demographic data were obtained from graduates of Accreditation Council for Graduate Medical Education (ACGME)-accredited US plastic surgery residency programs between the years of 2005 and 2010. The type of practice and pursuit of fellowship were recorded for each graduate. Sex, age at graduation, marital status, dependents, advanced degrees, previous research, type of training program, primary residency, and length of plastic surgery training were also documented. Comparison of outcomes between the two plastic surgery training pathways (integrated vs independent) was analyzed. Data were collected for 424 graduates from 37 different training programs. Of these programs, 11% were from the West coast, 32% from Midwest, 33% from East coast, and 24% from the South. Seventy-nine percent of residents were male, mean age at graduation was 35 (2.89) years. Forty-nine percent of residents were married, 30% had one or more dependents, 6% had advanced degrees, and 18% had previous research experience. Fifty-eight percent of graduates were from independent programs. Forty-eight percent of residents pursued private practice immediately after graduation, 8% pursued academic practice, 41% pursued specialty fellowships, and 3% had military commitments. Most of the residents chose to pursue private practice on completion of residency. Independent residents were significantly more likely to pursue private practice immediately compared to integrated/combined residents. No other factors were significant for practice choice.

Perforator flaps in breast reconstruction.

Patients are well informed and seek autogenous breast reconstruction. The motivating factors include a preference for autologous tissue reconstruction and the complementary improvement in body contour, safety concerns surrounding implants, and implant-related complications in the setting of previous radiation therapy. In this article a variety of perforator flaps from donor sites that include the trunk (thoracodorsal artery perforator and intercostal artery perforator), abdomen (deep inferior epigastric artery perforator and superficial inferior epigastric artery), and buttock (superior gluteal artery perforator and inferior gluteal artery perforator) are described. Flaps from the trunk can be pedicled for partial breast reconstruction, and free flaps from the other donor sites can completely restore a natural-looking breast. The information obtained from preoperative CT and MRI can direct the surgeon toward the most successful operative plan. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article reviews pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.

Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction.

BACKGROUND: Pedicled and free transverse rectus abdominis musculocutaneous (TRAM) flaps remain popular for autologous breast reconstruction, but the incidence of abdominal donor-site bulge and hernia is significantly greater when compared with deep inferior epigastric artery perforator (DIEP) flap reconstruction. Mesh repair after muscle harvest, however, may reduce the complication rate to that observed with perforator flaps alone. METHODS: A retrospective review of all free flap breast reconstructions at the University of California, Los Angeles Medical Center from 2002 to 2007 was performed. Abdominal bulge and hernia were noted for patients undergoing free TRAM and muscle-sparing free TRAM flap reconstructions and were compared with those observed following DIEP flap reconstructions. RESULTS: A total of 275 free TRAM plus muscle-sparing free TRAM flaps and 200 DIEP flaps were performed. Among patients with free and muscle-sparing free TRAM flaps, 11.3 percent were found to have postoperative abdominal bulge or hernia. Only 3.5 percent of DIEP flap patients had abdominal complications. Incorporating mesh into the rectus fascia repair significantly reduced the abdominal complications reported to 5.1 percent. Of the 86 free and muscle-sparing free TRAM flaps that were bilateral, 12.8 percent had hernias/bulges. Use of mesh with bilateral free and muscle-sparing free TRAM flaps reduced the complication rate to 3.7 percent. CONCLUSIONS: Incorporating mesh into rectus fascia repair in free and muscle-sparing free TRAM flap cases significantly reduces the rate of postoperative abdominal complications to levels equivalent to those for DIEP flap reconstructions. The authors advocate deciding intraoperatively between DIEP and muscle-sparing free TRAM flap dissections based on ease of dissection and whichever offers optimal safety and flap perfusion. Routine use of mesh in donor-site repair will decrease postoperative abdominal morbidity in unilateral and bilateral cases.

Histologic analysis of Schwann cell migration and peripheral nerve regeneration in the autogenous venous nerve conduit (AVNC).

Over the last two decades, the autogenous venous nerve conduit (AVNC) has been established as an effective treatment modality for the repair of nerve gaps less than 3 cm. In this study, the spatial-temporal progression of Schwann-cell migration and peripheral-nerve regeneration across a 10-mm gap bridged by a venous conduit was examined, using immunoctyochemical techniques. Histologic analysis revealed that the process of nerve regeneration through an AVNC occurs in four phases: the hematoma phase, cellular migration phase, axonal advancement phase, and myelination and maturation phase. The authors found that: 1) the lumen of the vein conduit remains patent throughout the process of nerve regeneration; 2) Schwann cells migrate into the vital space of the vessel lumen from the proximal and distal nerve stumps; 3) axonal growth into the conduit lags behind Schwann-cell migration; 4) Schwann cells migrate to the regenerating axons to form mature nodes of Ranvier when the distal stump is present; and 5) mechanical injury alone is sufficient to induce axonal outgrowth from the proximal nerve stump.