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Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Afonso, Anoushka M.D.; Oskar, Sabine M.P.H.; Tan, Kay See Ph.D.; Disa, Joseph J. M.D.; Mehrara, Babak J. M.D.; Ceyhan, Jihan N.P.; Dayan, Joseph H. M.D.

Plastic and Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1053-1061
doi: 10.1097/PRS.0000000000003235
Breast: Original Articles
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Background: At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

Methods: A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

Results: In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre–enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre–enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

Conclusion: The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.


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New York, N.Y.

From the Departments of Anesthesiology and Critical Care, Epidemiology and Biostatistics, Plastic and Reconstructive Surgery, and Nursing, Memorial Sloan Kettering Cancer Center.

Received for publication May 27, 2016; accepted October 12, 2016.

Disclosure:None of the authors has financial interests in any of the products, devices, or drugs mentioned in this article. Dr. Afonso is on the Health Outcomes Advisory Board at Pacira Pharmaceuticals and received an educational grant to help defray travel costs to present at the 2016 Miami Breast Cancer Conference. The authors have no other conflicts of interest to declare.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch. On the iPad, tap on the Hot Topics icon.

Joseph H. Dayan, M.D., Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, N.Y. 10065-6007,

Copyright © 2017 by the American Society of Plastic Surgeons