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Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should It Become the Standard of Care?

Kaoutzanis, Christodoulos, M.D.; Ganesh Kumar, Nishant, M.D.; O’Neill, Dillon, B.A.; Wormer, Blair, M.D.; Winocour, Julian, M.D.; Layliev, John, M.D.; McEvoy, Matthew, M.D.; King, Adam, M.D.; Braun, Stephane A., M.D.; Higdon, K. Kye, M.D.

Plastic and Reconstructive Surgery: April 2018 - Volume 141 - Issue 4 - p 841-851
doi: 10.1097/PRS.0000000000004197
Breast: Original Articles

Background: Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue–based breast reconstruction before and after the implementation of an enhanced recovery pathway program.

Methods: The authors retrospectively reviewed consecutive patients who underwent autologous tissue–based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre–enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed.

Results: Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups.

Conclusion: Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue–based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings.


Nashville, Tenn.; and Ann Arbor, Mich.

From the Departments of Plastic Surgery and Anesthesiology, Vanderbilt University Medical Center; and the Department of Surgery, Section of Plastic Surgery, University of Michigan.

Received for publication July 23, 2017; accepted October 20, 2017.

Presented at the 2018 American Society of Reconstructive Microsurgery Annual Meeting, in Phoenix, Arizona, January 13 through 16, 2018.

Disclosure:None of the authors has a financial interest in any of the products, devices or drugs mentioned in this article.

Christodoulos Kaoutzanis, M.D., Department of Plastic Surgery, Vanderbilt University Medical Center, D-4207 Medical Center North, Nashville, Tenn. 37232-2345,

Copyright © 2018 by the American Society of Plastic Surgeons