Reducing Length of Stay after Microsurgical Breast Reconstruction with a Standardized Postoperative Protocol

Abstract

Background Despite widespread acceptance of enhanced recovery after surgery protocols in other surgical specialties, plastic surgery has been slow to adopt fast-track principles. Recently, however, studies have shown that patients undergoing microsurgical breast reconstruction may benefit from a comprehensive postoperative protocol. Methods All microsurgical breast reconstructions with abdominal free flaps performed by the senior author (A.K.) at a single institution from June 2009 to December 2013 were reviewed. Demographic information (e.g., age, body mass index, and comorbidities), operative details (e.g., laterality, type of flap), and postoperative data (e.g., complications, length of stay) were collected from patients' medical records. The authors employed a universal comprehensive protocol that dictated all postoperative care as it relates to diet, ambulation, flap monitoring, anticoagulation, analgesia, venous thromboembolism, antibiotic prophylaxis, and discharge criteria. Results During the study period, 161 patients underwent 289 free flaps. The average length of stay for all patients was 3.26 ± 1.19 days. The incidence of complications requiring return to the operating room was 4.35% (7 patients). The incidence of flap failure was 0.69% (2 of 289 flaps). Only one flap failure occurred after hospital discharge. Statistical analysis demonstrated that the presence of any complication requiring return to the operating room increased hospital course by an average of 1.37 days (p = 0.0027). Conclusion The standardization of postoperative care for patients undergoing microsurgical breast reconstruction results in a short hospital length of stay without increasing the incidence of flap failure or postoperative complications requiring return to the operating room.

Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

“…ERAS protocols have demonstrated ability to standardize postoperative stays and facilitate discharge. [12][13][14][15][16][17] Our study has exhibited the influence of patient expectation of discharge. We have shown that setting an expectation of a particular early discharge date can significantly affect the LOS.…”

“…In this study, patients who were discharged earlier had a similar complication rates to those had a standard discharge and no patients had flap loss Several studies have analyzed ERAS protocols for microvascular breast reconstruction and have found decreased postoperative narcotic use and LOS. [12][13][14][15][16][17]29 Batdorf et al found that in their ERAS cohort of 49 individuals, they were able to reduce LOS from 5.5 to 3.9 days. 13 Astanehe et al similarly published a study on ERAS protocols for microvascular breast reconstruction, finding that the LOS for their ERAS cohort was 4.8 days, compared with their traditional cohort's LOS of 6.6 days.…”

“…Future studies could focus on patient preference on hospital stay and if a reduced hospital stay leads to decreased satisfaction score. Although ERAS protocols and new surgical techniques have proven to reduce LOS, [12][13][14][15][16] there is still room for standardizing postoperative protocols. Despite having relatively small sample sizes, our study highlighted influence that plastic surgeons can have on the LOS for patients receiving DIEP flaps.…”

“…The implementation of enhanced recovery after surgery (ERAS) protocols has improved postoperative pain, minimized narcotics, and reduced LOS without increasing postoperative adverse effects. [12][13][14][15][16][17] The literature also shows that transversus abdominis plane (TAP) blocks reduce the level of narcotics that patients require to control their pain after abdominally based breast reconstruction. 18,19 Goals of DIEP flap postoperative protocols include enhanced patient outcomes, improved pain control with minimizing narcotics, and controlling costs with decreasing LOS.…”

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety

“…Previous studies have analyzed the efficacy of various enhanced recovery after surgery (ERAS) protocols in microsurgical, DIEP, and alloplastic breast reconstruction cases. [28][29][30] This study aims to evaluate outcomes with this particular DIEP pathway to assess its safety and feasibility in clinical practice at a major academic medical center.…”