PURPOSE: Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease the pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opiate use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction.
METHODS: A retrospective review was performed of patients at a single institution undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OMEs]), and discharge prescriptions. Comparisons were made using chi-square and Student’s t tests, where appropriate.
RESULTS: Two hundred thirty-one patients were identified (mean age, 48.8 years), of whom 137 (60%) underwent prepectoral and 94 (40%) subpectoral tissue expander placement. All but 2 prepectoral patients and 2 subpectoral patients were opiate naive. The prevalence of psychiatric comorbidities or chronic pain disorders was not significantly different between either cohort (P = 0.746 and P = 0.680, respectively). Neither the rate of bilateral procedures (P = 0.490) nor axillary dissections (P = 0.821) differed between cohorts. Overall, 92% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (1.07 days prepectoral versus 1.17 days subpectoral; P = 0.0891). Two subpectoral and 2 prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and—for subpectoral patients—cyclobenzaprine. Inpatient opioids were offered on an “as needed” (PRN) basis. Opiate usage within the first 24 hours was halved in the prepectoral cohort (22.2 versus 44.5 OME; P = 0.0003). However, patients with a chronic pain disorder (n = 13) had significantly increased opioid usage (P < 0.00001). The presence of anxiety (P = 0.9636) or depression (P = 0.5822) did not have a significant association with opioid use. In addition, the amount of opiates prescribed on discharge (308.42 OME prepectoral versus 336.99 subpectoral; P = 0.3197) and the rates of opioid refills (19% prepectoral versus 29% subpectoral; P = 0.084) were not significantly different between cohorts.
CONCLUSION: Prepectoral tissue expander placement seems to be associated with a 50% reduction in inpatient opiate usage postoperatively compared to subpectoral placement. This may represent an opportunity to improve patient safety and satisfaction by decreasing outpatient opiate prescriptions.