Secondary Logo

Share this article on:

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

Hart, Alexandra M., M.D.; Broecker, Justine S., M.D.; Kao, Leslieann, M.D.; Losken, Albert, M.D.

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 611–620
doi: 10.1097/PRS.0000000000004636
Breast: Special Topic
Discussion
Editor's Pick

Background: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery.

Methods: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded.

Results: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication.

Conclusions: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Atlanta, Ga.

From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine.

Received for publication September 27, 2017; accepted March 1, 2018.

Presented at the 60th Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, in Sea Island, Georgia, June 11 through 15, 2017.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Albert Losken, M.D., 550 Peachtree Street NE, Suite 9000, Atlanta, Ga. 30308, alosken@emory.edu

The rising use and abuse of opioids is a national epidemic.1 Over the past 15 years, there has been a rise in the consumption of opioid prescriptions1 that has paralleled an increase in the number of opioid-related overdoses reported, with over 11,000 in 2007 alone. As opioid-related deaths have increased, so have the number of opioid prescriptions. Since 2000, over 165,000 deaths are attributable to prescription opioid overdoses.2 Overprescribing by physicians has been shown to be a major contributor to the morbidity and mortality of opioid abuse and overdose death.1 Despite this, the number of opioids prescribed every year continues to increase.3 In March of 2016, the Centers for Disease Control and Prevention released clinical guidelines for chronic pain management.4 However, there is very minimal, if any, guidance on management of opioids in the acute postoperative setting.4–7 Moreover, very little research has investigated the current opioid prescribing practices following ambulatory surgery.

According to American Society of Plastic Surgeons statistics, 40,650 breast reductions and upward of 70,000 secondary breast operations were performed in 2015.8 The majority of these took place in ambulatory surgery settings. According to Kehlet et al., 50 percent of patients developing chronic pain do so after an acute surgical procedure.9 Therefore, it is important for physicians to adequately treat postoperative pain while being mindful of the individual risks and societal problem of excess opioids in circulation. There have been recent reports showing increased dependence on opioids following outpatient orthopedic procedures.10 In one such report of 250 patients following elective hand surgery, Rodgers et al. showed that the average patient had 19 unused tablets,11 and the majority used opioids for 2 days. This large discrepancy in the number of pills used compared to the number needed may contribute to the country’s opioid epidemic.

Because guidelines from regulatory bodies are lacking, we sought to determine how effective our current pain management regimen was at reducing postoperative pain. In addition, we were interested in the number of opioid tablets left over following these procedures to determine whether we were contributing to the national epidemic. The objective of this study was to prospectively analyze the level of pain control and patient satisfaction with pain control in breast reduction and secondary breast reconstruction patients following outpatient elective surgery.

Back to Top | Article Outline

PATIENTS AND METHODS

This is a prospective analysis of a consecutive series of patients after outpatient breast surgery at a single institution performed by one senior surgeon (A.L.). This study was approved by our institutional review board. All patients that presented for breast reduction or secondary breast reconstruction surgery (September of 2016 to October of 2017) were offered enrollment. Patients were scheduled for surgery at the discretion of the senior author. Secondary breast reconstruction procedures included implant exchange, capsulectomy/capsulotomy, fat grafting, scar revision, nipple reconstruction, and/or combination. The primary procedure was determined from the operative note as either the first procedure listed or the indication for the operation. As long as it was outpatient surgery, patients receiving multiple procedures were included. Patients with allergies to oxycodone/acetaminophen or documented history of chronic pain medication or opioid use were excluded. Other adjunct forms of local anesthesia including subcutaneous injection, liposomal bupivacaine, paravertebral or other local blocks were not routinely used.

Back to Top | Article Outline

Postoperative Pain Regimen

The study pain regimen was determined from a poll of the practices of all faculty physicians at our institution over the previous 6 months. Participants received a single prescription for 30 tablets of oxycodone hydrochloride 5.0 mg/acetaminophen 325 mg (U.S. Pharmacopeia) postoperatively.

Back to Top | Article Outline

Preoperative Survey

Before surgery, patients were given the Pain, Enjoyment, General Activity survey, which is a three-item scale assessing pain intensity and interference. This is a previously validated and reliable assessment of pain shown to be sensitive to change among patients with and without pain (Fig. 1).

Fig. 1

Fig. 1

Back to Top | Article Outline

Postoperative Survey

Postoperatively, patients were contacted by means of telephone three times: postoperative days 3 to 5, postoperative days 8 to 10, and after postoperative day 30. If the first attempt was unsuccessful, two additional attempts were made. At that time, no further attempts were made for that particular period. However, an attempt was made at the subsequent period (e.g., if we were unable to contact the patient three times from postoperative days 3 to 5, an attempt was made at postoperative days 8 to 10).

At each contact, patients were asked 17 questions including the following: Pain, Enjoyment, General Activity survey; questions on pain medication habits; side effects; and supplemental medication use. Participants were also asked a subset of questions from the BREAST-Q Postoperative Reduction Module Satisfaction with Outcome and the BREAST-Q Postoperative Reconstruction Module Satisfaction with Information domains (Fig. 2) to assess patient satisfaction with their pain management.

Fig. 2

Fig. 2

Back to Top | Article Outline

Data Collection

Demographic/clinical data were obtained from the electronic medical record. Postoperative complications within 30 days were recorded. Documented complications included unanticipated return to the operating room, unanticipated readmission, breast seroma (fluid collection requiring aspiration), hematoma requiring evacuation, infection treated with oral/intravenous antibiotics or operating room washout, mastectomy skin flap necrosis requiring serial dressing changes/débridement, nipple ischemia/necrosis (requiring serial dressing changes/débridement), and implant failure (exposure or infection requiring implant removal without immediate replacement). Major complications were any of the above that required unanticipated readmission or return to the operating room. All others were considered minor.

Back to Top | Article Outline

Statistical Analysis

For the purpose of determining opioid use habits, the breast reduction and secondary breast reconstruction patients were divided into two groups. The breast reduction patients were felt to have less preoperative opioid exposure, whereas the secondary breast reconstruction patients had surgery in the recent past.

Descriptive statistics were calculated for both groups. As appropriate, the independent-samples t test, Mann-Whitney U test, Fisher’s exact, and chi-square test were used. Percentages for each question were determined based on the number of respondents that answered that particular question. If a patient did not answer a question, they were not included in the calculation. Change scores for the questions were calculated by subtracting the score for each postoperative question from its corresponding preoperative score. The number of opioid pills left over was based on starting with 30. A value of p < 0.05 was used to determine significance. All statistical analysis was conducted using IBM SPSS Version 24.0 (IBM Corp., Armonk, N.Y.).

Back to Top | Article Outline

RESULTS

Patient Population

Ninety-five patients were included in the analysis: 60 secondary breast reconstruction (Table 1) and 35 breast reduction patients (Table 2). There was a 94.0 percent (n = 33 of 35) response rate in the breast reduction group and an 85.0 percent response rate in the secondary breast reconstruction group (n = 51 of 60). The most common procedure performed in the secondary breast reconstruction group was implant exchange [n = 31 (54.4 percent)], and the average number of procedures performed was three (range, one to seven). The most common technique of breast reduction was a superomedial nipple pedicle [n = 25 (71.4 percent)] with a Wise pattern skin reduction [n = 33 (94.3 percent)].

Table 1

Table 1

Table 2

Table 2

The overall complication rate was 9.5 percent (n = 9), which was similar between groups [secondary breast reconstruction, n = 6 (10.3 percent); breast reduction, n = 3 (8.9 percent)] (Table 3). There was no significant difference between responders and nonresponders for any of the demographic or clinical variables for both the secondary breast reconstruction and breast reduction groups. All patients included had preoperative Pain, Enjoyment, General Activity survey data that were also similar between the postoperative responders and nonresponders.

Table 3

Table 3

Back to Top | Article Outline

Pain, Enjoyment, General Activity Survey Results

Total Cohort

Inclusive of all patients, the mean pain score preoperatively was 2.81 (Fig. 3). There was a slight increase to 4.81 at postoperative days 3 to 5, followed by a decrease to 3.59 at postoperative days 8 to 10. At greater than postoperative day 30, the mean pain score was 3.00. When asked how pain interfered with enjoyment, the average preoperative score was 2.22, with an increase to 4.11 on postoperative days 3 to 5. The mean score stayed at 4.81 at the conclusion of the study. Similarly, the mean score for how pain affected general activity was 2.4 preoperatively. At postoperative days 3 to 5, the average score was 4.75, which was stable at 5.06 on postoperative day 30.

Fig. 3

Fig. 3

Back to Top | Article Outline

Secondary Breast Reconstruction Group

The mean preoperative pain score for the secondary breast reconstruction patients was 1.95 (Fig. 4). Patients that reported taking any of the opioids prescribed had significantly higher preoperative pain scores than those that did not (2.41 versus 0.10; p = 0.008). Patients reported increased pain at postoperative days 3 to 5 (score, 4.69). At postoperative days 8 to 10, the average pain score was 3.32, which was similar at postoperative day 30 (score, 3.28). The secondary breast reconstruction patients also had very mild pain scores for how pain interfered with enjoyment (score, 1.40) and general activity (score, 1.62) preoperatively. At postoperative day 30, the mean score was 4.77 for how pain interfered with enjoyment and 5.08 for how pain interfered with general activity.

Fig. 4

Fig. 4

When the secondary breast reconstruction group was stratified by procedure type, there was no significant difference in the mean number of opioid tablets left over at postoperative day greater than 30 and primary procedure (p = 0.931) (Table 4). The postoperative Pain, Enjoyment, General Activity survey scores were also similar among all procedures for all three time points (postoperative days 3 to 5, p = 0.240; postoperative days 8 to 10, p = 0.678; postoperative day greater than 30, p = 0.752). In addition, there was no significant difference between Pain, Enjoyment, General Activity survey scores and the number of procedures performed.

Table 4

Table 4

Back to Top | Article Outline

Breast Reduction Group

For the breast reduction group, the preoperative pain score was 4.24 (Fig. 5). There was not a significant difference in preoperative pain scores between patients that did and did not take opioid medication (p = 0.176). After a slight increase to 5.10 on postoperative days 3 to 5, the mean score at postoperative days 8 to 10 was 4.33. This further declined to 1.40 at postoperative day 30. When asked how pain interfered with enjoyment and general activity, the mean score preoperatively was 3.58 and 3.70, respectively, but the mean score at postoperative day 30 for both was 0.60.

Fig. 5

Fig. 5

Back to Top | Article Outline

Pain Medication Use

At the conclusion of the study, 75.0 percent of secondary breast reconstruction patients (n = 36 of 48) and 72.0 percent of breast reduction patients (n = 18 of 25) took at least one opioid tablet (Table 5). Patients reported taking opioids for 8.5 days after secondary breast reconstruction and 11.1 days after a breast reduction. The most common reason for discontinuing the opioid medication was that pain was well controlled (secondary breast reconstruction, 71.4 percent; breast reduction, 73.9 percent). At postoperative day 30, 7.1 percent of the secondary breast reconstruction patients were still taking opioid medications, whereas none of the breast reduction patients were. For those that discontinued opioids, a mean of 18.6 tablets were left over in the secondary breast reconstruction group and a mean of 12.5 (range, zero to 26) tablets were left over in the breast reduction group (range, zero to 29).

Table 5

Table 5

The majority of patients used over-the-counter supplemental pain medication (secondary breast reconstruction, 77.1 percent; breast reduction, 64.0 percent). The most common was any of the nonsteroidal antiinflammatory medications. There was not a significant difference in Pain, Enjoyment, General Activity survey scores between patients that used supplemental medications and those that did not for the breast reduction group. In the secondary breast reconstruction group, patients that used supplements had a mean pain score of 5.09 versus 1.33 for those that did not on postoperative days 3 to 5. There was no significant difference in Pain, Enjoyment, General Activity survey scores for any other time points.

By postoperative day 30, 38.3 percent of the secondary breast reconstruction patients and 53 percent of the breast reduction patients reported experiencing side effects from opioids. Opioids were discontinued because of side effects in 16 percent (secondary breast reconstruction) and 9.1 percent (breast reduction). The most common side effect experienced was difficulty sleeping and/or bad dreams (secondary breast reconstruction, 58.8 percent; breast reduction, 50.0 percent).

Back to Top | Article Outline

Patient Satisfaction

The majority of patients reported that they were very satisfied with their pain management (secondary breast reconstruction, 79.5 percent; breast reduction, 80.0 percent) (Table 6). Similarly, most were very satisfied with how long it took to feel normal and definitely agreed that, overall, surgery was a positive experience (secondary breast reconstruction, 83.3 percent; breast reduction, 92.0 percent) and would do it again. Furthermore, most patients definitely agreed that they had no regrets about undergoing surgery.

Table 6

Table 6

Back to Top | Article Outline

DISCUSSION

The overprescribing of opioids is a national epidemic, with physicians poised to help limit the abuse, misuse, and overabundance of opioids on the market. Because of the lack of guidelines, physicians are led to believe that more is better, often giving patients extra medication “just in case.”11 , 12 Without the ability to “call in” more opioids if needed, many physicians feel they should give all patients an excessive number in case they run out at night or on the weekend. At our institution, we assented to this dogma that more medication was equal to better pain control and satisfaction. In this report, 95 patients received a single prescription of 30 opioid tablets after ambulatory surgery. The postoperative pain scores were low, and patients felt pain management met expectations. Our results echo those from other reports of ambulatory orthopedic and hand surgery practices that show leftover opioid tablets after minor surgical procedures.11 , 12 As a group, surgeons are often overprescribing opioids to patients, leading to a large number of leftover opioids in circulation.

According to our results, most patients had 12 to 18 leftover tablets. For many patients, an excessive number of narcotics were given without a proven benefit. Interestingly, 7.1 percent of secondary breast reconstruction patients were still taking opioids intermittently at greater than postoperative day 30. Because the pain scores following secondary breast reconstruction had trended back down to 3, it is unlikely that patients were still experiencing excessive pain. Many patients receive their first exposure to opioids after surgery. However, the absolute risk of new and persistent opioid abuse after surgical procedures has not been defined. In a cohort of 29,068 patients by Brummett et al., the authors found that following minor surgical procedures, 5.9 percent of patients filled an opioid prescription postoperatively, with a mean of three new prescriptions and over 200 pills per patient.13 In their analysis, tobacco use, alcohol abuse, anxiety, and mood disorders were independently associated with an increased risk for persistent opioid use in opioid-naive patients. Another recent study by Sekhri et al. evaluated 26,000 opioid-naive surgery patients to determine what percentage of patients refilled their prescription within 30 days.14 The authors found that 8.67 percent of patients refilled their prescriptions, but the probability of refill was not related to the amount given. Instead, across all procedures, the probability of obtaining a single refill was related to patient factors such as tobacco use, anxiety, and mood disorders. Although we did not evaluate the level of anxiety or mood symptoms in the secondary breast reconstruction patients, it has been previously shown that breast cancer patients are at increased risk of anxiety and depression often associated with the diagnosis of breast cancer.15 Elevated levels of anxiety have also been linked to increased risk for narcotic overuse and abuse.15 Although we cannot conclude that mood symptoms are related to the continued use of opioids, it is interesting that all of the breast reduction patients stopped all narcotics by greater than postoperative day 30, whereas 7.1 percent of the secondary breast reconstruction patients continued to use narcotics.

Furthermore, previous reports have shown that breast cancer surgery results in persistent moderate to severe pain in 15 to 20 percent of women.16 The persistence of pain after breast cancer surgery has been determined to be multifactorial and often related to preoperative risk factors such as elevated body mass index, axillary lymph node dissection, and other psychosocial factors.16 In an attempt to develop a clinical risk assessment tool, a recent analysis of three large cohorts of women was used to more clearly define risk factors for persistence of pain after breast cancer surgery. This analysis showed that higher postoperative pain scores were associated with persistence of pain greater than 1 year postoperatively. Most interestingly, the secondary breast reconstruction group was more likely to report that pain interfered with enjoyment and activity at a moderate level (4 to 5 of 10) despite having relatively low pain scores at the same time points. Perhaps these patients continue to experience persistent pain and anxiety above what is to be expected from the minor surgical procedure as a result of their original breast cancer surgery and not related to the acute postsurgical pain.17 Although our analysis excluded patients with a history of chronic pain, it is plausible that, following breast cancer surgery, women have a heightened sense of pain related to the experience of breast cancer and reconstruction.17 , 18 As the risk factors for persistent pain after breast surgery coincide with the risks for developing problems with long-term opioid use after surgery, perhaps opioid medications are not the best method for pain management after secondary breast reconstruction. The use of models such as those developed by Meretoja et al. are potentially helpful tools with which to predict which patients may be at risk for excessive postoperative pain regardless of the pain regimen prescribed.16 These tools could also be helpful to surgeons in identifying patients at higher risk for severe pain so that they may be referred to a pain specialist more quickly or given a nonopioid pain regimen. Further adding to the risks for opioid abuse is that breast reconstruction is often not a “one-and-done” phenomenon. Women often undergo one to four secondary breast reconstruction procedures over the course of a couple of years and receive opioids at each operation. In these patients, the risks for opioid abuse may be compounded as they experience anxiety related to their cancer diagnosis, some mild pain with each procedure, and continually have their life disrupted by postoperative pain.

Our prospective analysis has shown a decrease in pain scores from preoperatively to postoperatively following breast reduction. This is in keeping with previous reports that have found that, following breast reduction, patients experience improved pain and quality-of-life scores.19 , 20 However, there was still a substantial number of leftover tablets at the conclusion of our study. In this series of less than 100 patients, we found that there were a mean of 12.5 tablets left over for each breast reduction patient and a mean of 18.6 tablets left over for each secondary breast reconstruction patient. In total, there were 1551 tablets left over for the entire cohort. With an estimated street value of $5 per pill,21 the value of the leftovers from this study is approximately $7755. As it is likely that the majority of patients are not selling their leftovers, an excess number of opioids at home may offer easy access for other family members/friends with a history of abuse. Perhaps the monetary value of excess opioids following ambulatory surgery is not of major concern. Likely, the chief problem is the risk factor for long-term opioid abuse that has been shown to be associated with prolonged postoperative opioid use.13 , 22 , 23

The major limitation of our study is the small number of patients, which limited our ability to perform multivariate analysis using the previously defined risk factors for increased pain and opioid abuse. This report represents a single surgeon’s experience with potential selection bias. As a result of small sample size, these findings may not be generalizable among the general population. Nevertheless, we believe that this study is an important contribution to the growing literature on pain management. The strengths of this analysis are in the prospective design and well-defined inclusion criteria. In addition, all patients had surgery at the same institution performed by the same senior surgeon, which likely limits any difference in surgical technique that may influence postoperative pain.

Much attention has been paid to the use of opioid-sparing protocols such as the popular enhanced recovery after surgery protocol. Although there are numerous reports using the enhanced recovery after surgery protocol following autologous reconstruction, there has yet to be any study that uses this pathway in an outpatient setting for breast surgery.24–27 The majority of these protocols focus on microsurgical breast procedures and major operations that require inpatient hospital stays. Although these protocols are important, the majority of breast surgery is performed in outpatient centers8; therefore, it is necessary to better understand how to manage pain after breast surgery and treat it effectively. This is the first prospective analysis to assess the use habits and effectiveness of opioids in postoperative pain control following outpatient breast surgery.

Back to Top | Article Outline

CONCLUSIONS

Prescribing 30 opioid tablets following ambulatory breast surgery is excessive. The development of opioid-sparing pain regimens for inpatient microsurgical breast reconstruction further emphasizes the need for similar regimens in the outpatient setting. As the most common outpatient surgical procedure performed by plastic surgeons, management of pain after breast surgery is particularly important. It is our responsibility to understand our patients’ risk factors for opioid abuse and inadequate pain management to determine which patients may benefit from more opioids and which patients need less. The cookie-cutter approach to pain management is no longer appropriate.

Back to Top | Article Outline

REFERENCES

1. Baigian J, Cohen M, Barnsteiner J, et al; The Joint Commission; Patient Safety Advisory Group. Sentinel Event Alert. Safe use of opioids in hospitals. Available at: http://www.masimo.com/siteassets/us/documents/pdf/sea_49_opioids_8_2_12.pdf. Accessed September 5, 2017.
2. Frieden TR, Houry D. Reducing the risks of relief: The CDC opioid-prescribing guideline. N Engl J Med. 2016;374:1501–1504.
3. Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the United States. Pain Physician 2012;15(Suppl):ES9–ES38.
4. Wiesman J; Washington State Agency Medical Directors’ Group (AMDG) in collaboration with an Expert Advisory Panel, Actively Practicing Providers, Public Stakeholders, and Senior State Officials. Interagency guideline on prescribing opioids for pain, 2016. Available at: http://www.supportprop.org/resources/washington-state-interagency-guideline-on-prescribing-opioids-for-pain/. Accessed September 5, 2017.
5. Rana MV, Desai R, Tran L, Davis D. Perioperative pain control in the ambulatory setting. Curr Pain Headache Rep. 2016;20:18.
6. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131–157.
7. Waljee JF, Zhong L, Hou H, Sears E, Brummett C, Chung KC. The use of opioid analgesics following common upper extremity surgical procedures: A national, population-based study. Plast Reconstr Surg. 2016;137:355e–364e.
8. American Society of Plastic Surgeons. 2015 plastic surgery statistics report Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/cosmetic-procedure-trends-2015.pdf. Accessed March 20, 2016.
9. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet 2006;367:1618–1625.
10. Menendez ME, Mellema JJ, Ring D. Attitudes and self-reported practices of hand surgeons regarding prescription opioid use. Hand (N Y) 2015;10:789–795.
11. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37:645–650.
12. Kumar K, Gulotta LV, Dines JS, et al. Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits. Am J Sports Med. 2017;45:636–641.
13. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152:e170504.
14. Sekhri S, Arora NS, Cottrell S, et al. Probability of opioid prescription refilling after surgery: Does initial prescription dose matter? Ann Surg. 2017. [Epub ahead of print.]
15. Becherer BE, Kamali P, Paul MA, et al. Prevalence of psychiatric comorbidities among women undergoing free tissue autologous breast reconstruction. J Surg Oncol. 2017;116:803–810.
16. Meretoja TJ, Andersen KG, Bruce J, et al. Clinical prediction model and tool for assessing risk of persistent pain after breast cancer surgery. J Clin Oncol. 2017;35:1660–1667.
17. Belfer I, Schreiber KL, Shaffer JR, et al. Persistent postmastectomy pain in breast cancer survivors: Analysis of clinical, demographic, and psychosocial factors. J Pain 2013;14:1185–1195.
18. Edwards RR, Mensing G, Cahalan C, et al. Alteration in pain modulation in women with persistent pain after lumpectomy: Influence of catastrophizing. J Pain Symptom Manage. 2013;46:30–42.
19. Hernanz F, Fidalgo M, Muñoz P, Noriega MG, Gómez-Fleitas M. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. 2016;69:e168–e173.
20. Singh KA, Losken A. Additional benefits of reduction mammaplasty: A systematic review of the literature. Plast Reconstr Surg. 2012;129:562–570.
21. streetRx. Latest street prices for prescription drugs. Available at: http://streetrx.com/. Accessed August 28, 2017.
22. Inacio MC, Hansen C, Pratt NL, Graves SE, Roughead EE. Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: A retrospective cohort study. BMJ Open 2016;6:e010664.
23. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176:1286–1293.
24. Afonso A, Oskar S, Tan KS, et al. Is enhanced recovery the new standard of care in microsurgical breast reconstruction? Plast Reconstr Surg. 2017;139:1053–1061.
25. Batdorf NJ, Lemaine V, Lovely JK, et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68:395–402.
26. Dumestre DO, Webb CE, Temple-Oberle C. Improved recovery experience achieved for women undergoing implant-based breast reconstruction using an enhanced recovery after surgery model. Plast Reconstr Surg. 2017;139:550–559.
27. Temple-Oberle C, Shea-Budgell MA, Tan M, et al; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery After Surgery (ERAS) Society recommendations. Plast Reconstr Surg. 2017;139:1056e–1071e.
©2018American Society of Plastic Surgeons