Outpatient Microsurgical Breast Reconstruction

Abstract

Background: The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions. Methods: We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation. Results: Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care. Conclusions: By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap–based breast reconstructions can be performed with high success and low complication rates.

The Optimal Length of Stay after Microvascular Breast Reconstruction: A Cost-Utility Analysis

“…Traditionally, an 8-day length of stay was considered standard of care, 1 but the aforementioned advances often permit a dramatically reduced length of stay—as short as 1 day—in certain select patient populations. 2,3 Despite the fact that contemporary microvascular breast reconstruction patients often achieve the standard metrics for discharge criteria earlier in their postoperative course, many plastic surgeons are reticent to endorse a shorter hospitalization, citing the need for prolonged inpatient flap monitoring.…”

Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps

“…Previous publications have shown that DIEP flaps can be performed successfully on an outpatient basis. 1 , 7 The purpose of this study was to show that complex and multiple flaps can also be done without an extended hospitalization. To accomplish this, we employ a team-based model.…”

“…Additionally, our early recovery protocol, similar to other early recovery after surgery procedures, allows us to perform microsurgical breast reconstructions in an outpatient setting. This significantly decreases the length of stay without a rise in complication rates or hospital readmissions, 1 , 40 , 41 while offsetting the costs associated with perforator-based breast reconstructions. 42 , 43 …”

“…Throughout the course of the series, an early recovery autologous breast reconstruction protocol was implemented, facilitating expeditious discharge within 24 hours of surgery. 1 This protocol includes modified operative techniques with minimal anatomic disruption and no rib removal during preparation of the recipient vessels, microfascial incisions (DIEP) and fascial sparing (PAP) flap harvest. Additionally, our protocol includes a multimodal pain control regimen to minimize narcotic requirements and promote early mobilization and postoperative anticoagulation therapy.…”

Preoperative estimation of vertical profunda artery perforator flap weight using computed tomography angiography for breast reconstruction

“…Breast reconstruction with autologous tissue grafting after total or partial mastectomy for breast cancer is widely recognized as a standard procedure due to recent technological advances in microsurgery (Haddock, Gassman, et al, 2017; Martinez & Boutros, 2020). The deep inferior epigastric perforator (DIEP) flap is the most commonly selected free skin flap worldwide because it is harvested from the lower abdomen and thus can contain abundant fat tissue, and because there is little variation in the course of the deep inferior epigastric artery that serves as the feeding artery (Granzow et al, 2006; Guerra et al, 2004).…”