Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Introduction

Early reports discussing surgical physiology and its relationship with post-operative morbidity founded the introduction of “fast-track” surgery protocols in the early 2000’s (1-3). Research has since blossomed into enhanced recovery after surgery (ERAS), a field of itself, with numerous publications spanning most surgical subspecialties. These methods, aimed at optimizing the physiologic response to operation and anesthesia, have demonstrated reductions in factors including morbidity, length of stay, and costs (4). As of 2023, the international ERAS^® Society has collated 30 current consensus guidelines in 17 specialties, with focus on pre-operative optimization, anesthesia, opioid-sparing analgesia, and post-operative care (5).

Plastic surgery had a relatively late introduction to enhanced recovery, with Fayezizadeh et al. describing a protocol for abdominal wall reconstruction in 2014 (6). Research quickly saw exponential growth, particularly in breast surgery and head and neck reconstruction, leading to publication of consensus ERAS^® guidelines for each in 2017 (7,8). Breast reconstruction is a particularly interesting service for the study of enhanced recovery as it encompasses two dissident techniques, namely implant-based (alloplastic) and free-flap (autologous) reconstruction.

Alloplastic methods are of comparatively lower technical demand with significantly shorter operative times and historically lower immediate perioperative morbidity and post-operative length of stay. Thus, they are currently employed in approximately 75% of reconstructions (9). Meanwhile, less-frequently-offered autologous reconstructions have demonstrated long-term superiority in metrics ranging from complication rates, costs and quality of life (10-14). The goals of operative and recovery protocols should thus be two-fold; improving alloplastic outcomes and enhancing autologous offerings.

Since 2019, the authors’ group has worked to build on the consensus guidelines and enhanced recovery literature at-large to create a comprehensive and interdisciplinary pathway targeting these goals. Herein is a narrative review researching recovery after surgery for breast reconstruction with systematic description of reports and dissection into the facets of a comprehensive pathway. Each facet is described, with attention to available evidence, and discussed through the lens of the authors’ experience. We present this article in accordance with the Narrative Review reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1509/rc).

Methods

Following Preferred Reporting in Systematic Meta Analysis guidelines, the authors identified reports describing enhanced recovery protocols in alloplastic and autologous reconstructions (Figure 1, Table S1). The PubMed and Embase databases were queried with various search terms, and titles and abstracts were screened for inclusion by two independent blinded reviewers followed by retrieval and assessment of the full text. Initially included reports were those containing primary clinical research and focused on ERAS or improved outcomes with protocol description. Reviews and studies focusing on one specific protocol facet were initially excluded.

Figure 1 PRISMA flowchart of study identification and selection.

Initial inclusion criteria yielded 25 studies. Five were focused on alloplastic reconstruction with year of publication ranging from 2017–2020 (15-19). Twenty were focused on autologous reconstruction with publication ranging from 2015–2022 (20-39). Study characteristics, descriptions, and conclusions are provided (Tables 1,2). Ten reports outside of the initial criteria were additionally included to enhance the narrative (40-49). Descriptions and reasoning for inclusion are provided (Table 3).

The narrative review is divided into sections on pre-hospital, pre-operative, intra-operative, inpatient, and outpatient care. Both alloplastic and autologous reconstruction are included, but significant attention is given to autologous as the literature is significantly denser. Special topics including costs and protocol adoption are ultimately discussed, and the key pieces of a compressive protocol are outlined.

Discussion

Pre-hospital

Enhanced recovery protocols in breast reconstruction often start in the clinic, with patient selection, education, expectation setting, and surgical optimization.

Selection criteria

As much of the literature focuses on expedited discharge, selection often hinges on safe outpatient care. In the alloplastic literature, reported criteria included well-controlled comorbidities, American Society of Anesthesiologists (ASA) class I or II (excluding patients with severe systemic disease), BMI <35 kg/m², and metastatic cancer (16-19). Notably, two studies by Dumestre et al., which were focused on a protocol for same-day discharge, also described the importance of home support. Patients were only enrolled into the pathway if they had another capable adult at home and lived within an hour of the institution (18,19). Generally, autologous reports described similar criteria, with additional exclusions for age >70 years, contra-indication to local anesthetic, current smoking, chronic opioid use, narcotic abuse history, chronic pain syndromes, and sleep apnea (28,32,43,46,49). Otherwise, many studies reported that all patients were enrolled without exclusions. The authors’ program enrolls all patients, but attention is paid to the criteria described and elements are tailored to the individual when indicated.

Education and expectations

Patient-centered education and expectation setting played a major role in many reports. Notable examples include provision of pamphlets (17), figure-based discussions (25,37), and classes with specialized nurses (27,42). Two autologous studies describe the specific power of expectations and norms by demonstrating significantly reduced length of stay after simply shortening that expected by patients, surgeons, and staff (40,47). These reports show profound simplicity in that all the authors modified was set an expectation ahead of surgery and tell the patients and staff it was possible. With just this, they were able to reduce the length of stay by at least a day. These findings emphasize the importance of patient expectation management as part of an enhanced recovery protocol. The psychological component of patient expectations and concerns must be considered, as it can constitute a barrier to optimal recovery. It appears that this aspect is easily addressed by timely and adequate patient education.

Interestingly, while the 2017 ERAS^® consensus guidelines provided a strong recommendation for pre-hospital counseling and education, there is no mention of expectation-setting and a paucity of research on specific education elements or delivery (7). The authors have had success with a short, nurse-created video detailing inpatient and outpatient recovery and surgeon directed expectation setting at initial consultation. These goals set early, serve as a foundation for achievement after surgery.

Optimization

The consensus guidelines likewise provide a strong recommendation for pre-hospital patient optimization including varying levels of evidence supporting glycemic control, BMI reduction, smoking cessation, and alcohol abstinence (7). Unfortunately, the timeline of breast reconstruction makes optimal surgical candidacy challenging and the arguably non-elective nature of the procedure limits patient selection for many surgeons. In the current literature, optimization counseling/encouragement includes smoking cessation, alcohol reduction or abstinence, exercise, and healthy diet (23,24,31,32,43,46).

Three reports specifically discussed nutritional optimization. Sindali et al. noted this to be of particular importance but did not provide detail, Shin et al. described employed protein supplementation for 1 week, and Bamba et al. provided high-calorie nutritional beverages for 5 days pre-operatively (31,40,42). While pre-operative nutrition may have potential value, the concept is presently understudied with sparse evidence across all fields (50-52).

Fasting

The final piece of the pre-hospital recovery foundation is departing from the pre-operative fast, rooted in many years of tradition, for evidence-based practices including limited fasts, clears-only diets, and immediate pre-operative oral carbohydrate solutions (53). This principle was given strong recommendations in the consensus guidelines, namely a clears-only to 2 hours before the operation and an oral carbohydrate & electrolyte solution. But, this can be a challenging piece to enact as it requires interdisciplinary discussion and collaboration (7). Of included studies, 63% directly indicated limited fasting and 25% also described administering an oral solution. As these interventions were given moderate and low level of evidence respectively by consensus guidelines, further research into their efficacy may be warranted.

Pre-operative

Preemptive interventions may allow stronger control of intraoperative anesthesia and analgesia, ultimately leading to faster recovery and improved outcomes (54). Interventions can include opioid-sparing analgesia, anti-emetics, and local anesthesia. While the 2017 consensus guidelines also indicate prophylactic antibiotics and thromboprophylaxis, these represent the current standard of care and will not be discussed (7).

Analgesia

Theoretically, analgesics given to take effect prior to the operation could prevent postoperative pain through reducing nociceptor sensitization and partially mitigating local inflammatory and central pain responses (55,56). While this has good physiological backing, clinical evidence has not definitively proven efficacy, likely because of the complexity of pain pathways (57). Nonetheless, pre-operative analgesics were recommended in the 2017 consensus review under the umbrella of multimodal pain control, and were mentioned in 57% of studies included in this review (7). Most common was acetaminophen in various combinations with or without celecoxib and pregabalin or gabapentin. Additionally, five reports described administering opioids (19,28,32,34,46), one aspirin and ketorolac (40), and one Naprosyn (32). The use of non-steroidal anti-inflammatories (NSAIDs) is a particularly contentious and debated topic in surgery due to concerns of bleeding risk, but supporting evidence illustrates this is not a concern (58,59). While pre-operative analgesics don’t have proven benefit in post-operative pain control, it is arguable that they allow for fewer opioids and lower sedation intra-operatively. Although preoperative analgesia is not an essential component of ERAS protocols, it appears to be widely used. The potential benefits regarding reduction in opioid use and shorter hospital stays indicate it may be premature to dismiss it entirely. This goal-directed anesthesia is a key pillar, particularly in lengthy autologous reconstructions, which will be later discussed.

Anti-emetics

A 2020 Cochrane review demonstrated strong evidence for prophylactic post-operative nausea and vomiting prevention, particularly in combination and at multiple peri-operative time points. Those most commonly described for pre-operative administration were aprepitant, casopitant, ondansetron, rolapitant, and scopolamine (60). Pre-operative and intra-operative prophylaxis were additionally given a strong recommendation in the 2017 consensus review for breast reconstruction (7). Of included studies, 31% mentioned pre-operative administration of scopolamine patches or aprepitant, with one alloplastic and one autologous study noting administration based on risk assessment (15,35).

Regional anesthesia

Pre-operative regional anesthesia, in the form of peripheral nerve blocks, has demonstrated outstanding efficacy in limiting acute post-operative pain. Additionally, there is some evidence that these blocks may reduce incidence and severity of chronic post-operative pain through a mechanism similar to that described above (61-64). Pre-operative blocks are not specifically mentioned in the 2017 ERAS^® consensus, but methods such as transverse abdominis plane (TAP) blocks, which can be intraoperative or preoperative, are favorably reviewed (7). In this review, three groups employed pre-operative TAP blocks, and one group paravertebral or more-peripheral blocks, for autologous reconstruction (30,35,40,49). For alloplastic reconstruction, two groups employed paravertebral anesthesia, but Chiu et al. described preference for intra-operative ultrasound-guided pectoralis blocks (16,17).

The authors’ institution considers pre-intervention peripheral nerve blocks (primarily paravertebral) to be a cornerstone of recovery after breast reconstruction, wherein all not-contraindicated patients receive unilateral or bilateral upper thoracic block(s) and autologous patients receive bilateral lower thoracic blocks. This is made possible through tight-knit collaboration with a fellowship-trained anesthesiology service.

When enacting a block protocol, particularly one with the rigor allowed by partnership with specialists, an important consideration is whether single injection or continuous catheter is warranted (65). As regionals such as bupivacaine can maintain effect for multiple days and single injections can be given with enhanced accuracy, the authors’ group has evolved to avoid catheter implantation for both alloplastic and autologous reconstruction (63,66). In line with the authors’ experience, Jablonka et al. compared between TAP block with liposomal bupivacaine by injection or catheter, in autologous reconstruction, and found injection to be superior in peri-operative opioid requirements and length of stay (49).

Intra-operative

Collaboration across the curtain is key for optimal outcomes. Attention must be paid to maintaining physiologic norms, minimizing sedation and anesthetic load, and preemptively targeting post-operative hurdles. Goal-directed intra-operative practices can include tight thermic and volumetric control, regional anesthesia, sedation-sparing systemic analgesia and anesthesia, and minimizing time in the operating room.

Surgical physiology

The importance of physiologic core temperature during surgery or intervention has been discussed for decades, with literature-demonstrated benefit including superior wound healing and reduced complication rates (67,68). This is because hypothermia leads to peripheral vasoconstriction, lowers systemic pH through multifactorial mechanisms, and pathologically alters coagulative and immunologic cascades (69). Interestingly, the importance of maintaining normothermia was specifically mentioned in less than 20% of the captured studies. Presumably, this was selectively omitted by many as it has become standard care for most surgical teams.

Physiologic volume control is a more contentious topic in surgery with a long-reaching history. Rising popularity of fluid resuscitation from the early 20^th century led to potentially overzealous fluid provisions and subsequent reversal to fluid restrictions in by the early 21^st century (69,70). While fluid balance deserves further study in most surgical subspecialties, normovolemia is the current evidence-based standard for most recovery pathways and strict vitals-based control was recommended in the 2017 consensus review for breast reconstruction (7). When reported, the majority of included studies echoed the recommendations, with monitoring by urine production or cardiac output. Just two groups prescribed to fluid restriction, with Hammond et al. noting “judicious” fluid provisions in their alloplastic pathway and Linder et al. limiting fluids to 100 mL/h in autologous reconstructions (15,21). Notably, there is evidence that more-restrictive fluid administration is associated with improved peri-operative morbidity profiles in autologous reconstruction, particularly reduced incidence of abdominal wound complications (71,72).

Analgesia and anesthesia

Evidence of value for regional anesthesia was detailed above. While blocks could theoretically be of reduced efficacy if administered in the operating room, intra-procedural timing is commonly reported and has benefit in instances where an interventionist is not available, or the patient cannot tolerate a pre-operative block. More than half of included studies described some form of surgeon-administered intra-operative local anesthesia, most commonly TAP and/or pectoral and pre-incisional. The literature reflects variation in the type of blocks administered, both pre and intraoperatively. This to some extent appears to be a function of surgeon/institutional preference. The authors’ preference is for pre-operative blocks, but much of the literature reports equivalent success with employment intraoperatively.

In a 2021 National Surgery Quality Improvement Program (NSQIP) database study, Kotha et al. showed significant correlation between length of autologous reconstructive operation and length of inpatient stay (73). While the causes of this relationship are complex and multifactorial, prolonged anesthetic and opioid administration undoubtedly plays a role in perioperative morbidity (74,75). This demonstrates the importance of minimally sedative, minimally volatile, and opioid-sparing anesthesia protocols, particularly in prolonged cases such as bilateral autologous reconstructions.

The concept is partially reflected in the 2017 consensus review, which recommends total intravenous anesthesia (TIVA) for mitigation of postoperative nausea and vomiting (7). As anesthetic selection is often outside of the scope of the plastic surgeon, just 34% of included studies specifically mentioned these protocols. Notably, two studies described use of TIVA (17,34), and eight employed systemic ketamine and/or lidocaine (15,23,24,28,32,35,43,46). Additional analgesics included intravenous administration of non-opioids such as acetaminophen or ketorolac.

Antiemetics and additional considerations

The common use of antiemetics for enhanced recovery was discussed above. However, it should be again noted that provision of antiemetics in combination and multiple time points has demonstrated efficacy. In the 2020 Cochrane review, aprepitant given within 24 hours postoperatively demonstrated a relative risk of postoperative nausea and vomiting (PONV) of 0.26. Dexamethasone, which has shown additional efficacy in mitigation of postoperative inflammation and pain, demonstrated a relative risk for PONV of 0.51 (60,76). This is the intraoperative combination employed at the author’s institution, and was mentioned frequently in included studies.

Speed and efficiency

As important as minimizing the adverse effects of anesthesia and optimizing intraoperative physiology is limiting the patient’s exposure to these challenges. While alloplastic reconstructions can commonly take fewer than 3 hours, unilateral and bilateral microsurgical cases take approximately 6 and 10 hours respectively (73). Although it isn’t necessarily a component of ERAS protocols, safely maximizing speed and efficiency in the operating room should be an important consideration of the surgeon. In 2019, Sharma et al. reported reduction of unilateral autologous operating time by approximately 1 hour by instituting a ‘100 step’ process-mapped protocol (77). This was followed by Haddock and Teotia in 2021 who instituted a process-mapped co-surgeon protocol allowing for an average operative time of just under 4 hours in 50 consecutive bilateral reconstructions (78). While the variability and surgical training inherent to academic institutions likely makes such a feat impossible, process-mapping should be instituted in some form. The author’s academic institution has had success with implementation, when possible, of efficiency protocols. Although optimal efficiency may be difficult to achieve while teaching, in the authors’ experience training is not incompatible with protocols for operative-time reduction.

Post-operative

Protocols for inpatient recovery should optimize rehabilitation with focus on quickly preparing the patient for safe disposition.

Discharge goals

The steps to discharge can be visualized as a ladder including oral intake, mobility, gastrointestinal function, hygiene, pain control, and safety (Figure 2). This concept is well described in two early autologous studies by Bonde et al. which employed process mapping for identification of barriers to discharge on postoperative day (POD) 3 (37,38). Meanwhile, alloplastic protocols demonstrated focus on same-day discharge, as demonstrated by a 2020 report by Oxley et al. which attempted to retrospectively identify predictors of unanticipated admissions (44).

Figure 2 Staircase diagram depicting milestones for discharge. GI, gastrointestinal.

The ultimate goal should be a pathway allowing discharge of autologous patients on POD 1. To date, this has only been consistently demonstrated in a specialized setting by Martinez and Boutros (29). Furthermore, concern for microvascular failure makes expedited discharge a topic of contention (79). This, and optimal reported outcomes will be later discussed.

Disposition

Though not directly mentioned in the 2017 consensus review, the authors believe that immediate transfer from post-anesthesia care to a dedicated floor with protocol-driven care from specialized staff is invaluable (7). Similar disposition protocols after autologous reconstructions were mentioned by Batdorf et al. in 2015 and DelMauro et al. in 2019 (33,39). While maintenance of a dedicated unit may not be possible, ensuring appropriate training and understanding of staff is vital for optimal outcomes. This also affords the opportunity to avoid intensive care unit (ICU) admission, which is typically standard for hourly flap checks at the majority of institutions. The cost savings of avoiding ICU admission may be a valuable bargaining chip when propositioning health systems.

Many alloplastic protocols focus on reconstructions in the outpatient setting or with early POD 1 discharge. While it may not be possible to ensure ambulatory patients have reached the top of the ladder shown in Figure 2, methodologies for determining readiness and investigations into pitfalls are described. A protocol for same-day discharge was first described by Dumestre et al. in two 2017 studies (18,19). While these reports solely referenced ‘standard day-surgery criteria,’ they included important selection factors: patients followed the full ERAS protocol, ASA class <III, another capable adult at home, residence within 1 hour of the hospital, and booking as first or second surgery of the day. In 2021, Hammond et al. retrospectively demonstrated a same-day discharge rate of 52% in 151 patients and found nerve block to be a significant predictor. They further demonstrated unanticipated admission necessitated by pain in 15%, PONV in 14%, surgeon or patient request in 14%, and complication in 12%, with the majority of these being directly related to incomplete recovery protocol adoption (15). This once again shows the importance of norms, for providers and patients, as affirmed by Oxley et al. who demonstrated 35% of patients requiring unplanned admission in the primary hospital, most commonly secondary to oversedation, versus 4% in the ambulatory center (44).

Independence

Eating, drinking, and walking are obvious fundamentals to discharge which are naturally followed by gastrointestinal motility and hygiene. These milestones should be integral to any recovery pathway, included in preoperative education, and encouraged at every visit. With appropriate preparation and coaching, it is not unreasonable to expect many to reach a level of independence on post-operative day 1. As emphasized by Astanahe et al., early foley removal and early ambulation are key factors in achieving these goals (34). The 2017 consensus review gives strong recommendations to diet advancement and mobilization within 24 hours (7). Most included studies aligned or surpassed recommendations for ambulation with seven indicating initiation on POD 0 and/or no restrictions (21,28,35,39,40,42,49). Of notable importance, when applicable, is ensuring integrity of the abdominal wound through a moderately kyphotic position. Likewise, a knowledgeable physical therapist should be present, particularly during early baby steps.

Of included autologous studies, 41% indicated encouraging an immediate unrestricted or minimally restricted diet with most others indicating immediate clears-only diet and/or advancement by postoperative day 1. The latter option may be advisable in case of necessary re-operation. An interesting dogma which is at present maintained by the authors’ protocol, and was mentioned by Bamba et al., is abstinence from caffeine due to concern for contribution to vasospasm (40,80). A delve into the literature shows that this may not have much basic or clinical backing, with some evidence that supplementation may actually improve analgesia, motility, and recovery (81,82).

The controversy surrounding caffeine consumption and surgery appears to be a long standing, if unfounded one. Its effect on the microsurgeon was addressed by Dr. Acland decades ago in his Practice Manual for Microvascular Surgery (83). He notes that for the surgeon, abrupt changes in caffeine consumption are more deleterious than maintaining an established habit. Most research indicates that this principle is likely equally applicable to patients and their recovery. Provision of gum, with hope to stimulate motility through the gastro-colic reflex, was another described facet without particularly satisfying clinical evidence (84-86).

Fluids and lines

Adjacent to the above steps towards independence is weaning of intravenous fluids and, ultimately, removing all lines that can’t be brought home. Protocols for fluid discontinuation were mentioned, with various intricacies and limits, in 40% of included studies. Most focused-on discontinuation with adequate oral intake or within the first 48 hours. The necessity of other lines should be weighed against respective barriers to discharge. This was demonstrated by Jablonka et al. who achieved shorter length of stay and opioid use with regional anesthesia by single injection rather than catheter, and by Bonde et al. who found that scheduled removal of vacuum-assisted drains was necessary to achieve discharge goals (37,49).

Pain

The multifactorial benefit of regional anesthesia was previously detailed and represents a key foundation of peri-operative pain control and expedited recovery. While blocks inherently lose efficacy 2–3 days after administration, they are present to blockade the critical acute postoperative pain thus limiting sedative and opioid administration. This not only allows for more-immediate and steady rehabilitation, but mitigates adverse effects of traditional analgesics such as PONV, anorexia, and constipation.

Further, the authors recommend a protocolized scheduling of non-opioid analgesics such as acetaminophen, celecoxib, pregabalin, and NSAIDs in an appropriate combination. Some variation of this was reported in nearly every included study. Equally mentioned was the sparing use of PRN opioids for breakthrough pain, as these are valuable adjuncts that should not be dismissed entirely. While the ideal would be adequate pain-control without narcotics, a more realistic goal should be limiting administration to the extent that adverse effects are absent. Four included reports described administration of opioids by patient-controlled analgesia pump, but advocated for expedited removal (26,31,33,47). Given the body of evidence, these should probably be avoided entirely. Notably, Kaoutzanis et al. reported administration of intravenous lidocaine for 24 hours post-operatively (35). While there is evidence that this, through poorly understood mechanisms, may improve short-term recovery outcomes in some operations, it hasn’t demonstrated efficacy in breast surgery (87).

The authors’ group is fortunate to have strong collaboration between surgery and anesthesiology which includes peri-operative pain management by a dedicated anesthesiologist-driven acute pain service. While this is not a luxury available to all, collaborative planning of a multimodal analgesia protocol, including careful attention to indications and contraindications, should be pursued.

Safety

The ultimate consideration is patient safety, both inpatient recovery and after discharge. Employment of the methods described above assist the recovering patient in gaining independence and competence, thus providing the majority foundation for safe discharge. Specialized nurses, experienced staff, and protocolized care undoubtedly play a major role. Most pertinent to breast reconstruction is careful monitoring for microvascular compromise after flap-based reconstruction, a dreaded complication effecting approximately five percent of reconstructions (88). If identified within the first 24 hours, salvage rates are as high as 80%, but exponentially decline thereafter (89,90).

Several methods of monitoring were described in included studies. Most common was visual inspection and employment of a handheld doppler device. This was described in just 25% of autologous studies, with variable step-downs from hourly to every 4 hours, but is presumably the methodology used by most groups that didn’t provide specifics. Adjunctive use of a tissue oxygenation sensor was reported in five autologous studies (22,32,33,40,46). These devices provide valuable quantitative data, but have been recently demonstrated to have unfavorable cost-effectiveness (91).

As study and adoption of ERAS evolves, the potential for discharge of autologous patients on post-operative day 1 becomes increasingly feasible. This has been demonstrated in unpublished data at the authors’ institution and is reflected by Martinez and Boutros who, in addition to reporting consistent <24-hour discharge in 2020, are the first to describe employment of autologous flaps for “outpatient” cosmetic breast augmentations (29,41). Given consensus guidelines recommending flap monitoring for a minimum of 3 days, and a recent cost-effectiveness analysis by Mericli et al. concluding 3-day inpatient stay to be optimal, movement towards discharge on post-operative day 1 will undoubtedly be met with contention (7,79). By the authors’ approximation, given available data, discharge at 24 hours would theoretically lead to avoidable failure in an additional three to ten patients per thousand (79,88-90). This increase in risk should be discussed with the patient during pre-operative counseling, and advancement is necessary to mitigate the theoretical 100% failure rate if compromise occurs in the outpatient setting (79). Of note, the authors’ experience moving towards discharge on postoperative day 1 for all autologous reconstructions and without flap monitoring is yet to see microvascular compromise or flap failure in the outpatient setting. Akin to this, it may be reasonable to discontinue monitoring, after 24 hours, during inpatient stay. Complete discontinuation is controversial, but many authors note conversion to every-4- or every-8-hour checks.

Outpatient

Enhanced recovery pathways should not end in the inpatient setting, as described in the 2017 consensus review which gave strong recommendation to post-discharge care including physiotherapy programs, and support in the form of nurse-driven visits and provider availability by phone or app (7). Additional attention should be given to outpatient analgesia, clinical follow-up, and early identification of complications. In the authors’ experience, outpatient care can be greatly enhanced by patient-driven education both pre-operatively and during inpatient recovery. Interestingly, there was a relative paucity of follow-up description within the reports examined.

Discharge analgesia

The importance of opioid-sparing outpatient analgesia in preventing complications, including addiction, is well-known. Surprisingly, only a single included study, by Rendon et al., reported a metric of outpatient opioid requirements or made comparison with pre-pathway requirements. They demonstrated a significant and notable decreased opioid use of more than 300 oral morphine equivalents in the first postoperative month, but did not describe on the outpatient methods used for the achievement (28,92,93). Just four examined studies reported on discharge analgesia protocols, with O’Niell et al. prescribing 1-week scheduled acetaminophen & celecoxib & gabapentin, Stein et al. prescribing the same combination for 3 days, Dumestre et al. celecoxib & gabapentin for 2 days, and Jablonka et al. acetaminophen and ketorolac for 1 week (18,27,30,49). The authors’ have had success with a significantly more aggressive protocol which includes up to 1 month of scheduled acetaminophen and NSAID +/− gabapentin with an initial as-needed 50–100 mg oxycodone.

Follow-up

Reports including specific follow-up protocols were equally sparse. For outpatient alloplastic reconstructions, the protocol described Dumestre et al. described providing a 24-hour access telephone line to specialized nursing, with referral to surgeon as needed, and scheduled telephone follow-ups with a surgeon on POD 1 and 2. This accompanied strict safety-oriented selection criteria which are described above (18,19). Jablonka et al. noted scheduled clinical follow-up on postoperative day five which included surgical drain removal (49). These were, surprisingly, the only examined studies providing any detail. This leaves something to be desired, and potential for further exploration. It appears that further improvements could be made by many through adoption of literature-supported methods (94-96).

Outcomes

While detailed examination of outcomes respective to specific facets of recovery protocols, the following is an overview of outcomes described in the included studies. When enacting or evaluating a pathway, primary concerns should include opioid requirements at intra-operative, inpatient, and follow-up time points, length of inpatient stay, and adverse events. Patient-reported pain scores are another potential metric, but are infrequently reported due to their subjective and stochastic nature. Secondary considerations, which will be later discussed, should include cost-benefit analysis and implementation.

Opioid requirements

As previously discussed, opioid-sparing anesthesia can mitigate post-operative barriers including PONV and sedation. In yet unpublished research, the authors found employment of the methods herein to allow intraoperatively administered opioids to be significantly fewer than those in much-shorter alloplastic procedures using traditional anesthesia protocols. Of included studies, just one alloplastic and two autologous studies reported on this metric. Chiu et al. reported mean administration of ~25 mg intravenous morphine requirements (IV ME) in alloplastic cases (17). Meanwhile, in autologous studies, Ochoa et al. reported significant decrease with pathway enaction to mean 32 mg IV MME (milligram morphine equivalents) and Afonso et al. reported administration of just 22 mg IV ME.

Nine studies, focused on autologous reconstruction, reported on inpatient opioid requirements which ranged from approximately 10 to 60 mg IV ME (Figure 3). There was variability in length of stay and reporting, but these values can be generally approximated to represent post-operative day zero through three. Jablonka et al., whose 2017 study focused on the benefits of pre-operative regional anesthesia, reported the lowest mean requirement in a relatively small cohort of 54 patients (49). The largest study, consisting of 204 subjects, reported of mean of approximately 30 mg IV ME (22). The two next-largest studies, consisting of 138 and 139 subjects respectively, reported mean requirements of 19 and 44 mg respectively (24,32). In examining Figure 3, one can identify a relatively symmetric distribution of reports centered around a requirement of 30 mg IV ME. For reference, this approximates to 150 mg of oral oxycodone.

Figure 3 Inpatient IV MME reported in autologous reconstruction protocol studies. Width indicates number of subjects included in the study. From left to right: Jablonka et al. 2017 (49), Sharif-Askary et al. 2019 (32), Kaoutzanis et al. 2018 (35), Sindali et al. 2019 (31), Ochoa et al. 2022 (22), Haddock et al. 2021 (23), Haddock et al. 2021 (24), Astanehe et al. 2018 (34), Afonso et al. 2017 (36), Batdorf et al. 2015 (39). IV, intravenous; MME, milligram morphine equivalents.

Discharge

Most included alloplastic studies demonstrated that safe ambulatory reconstruction is feasible. In the earliest report, Dumestre et al. showed successful postoperative outpatient discharge in 72% of patients without significant difference in readmission, and with significantly improved patient reported outcomes, versus traditional and transitional cohorts (18,19). Later, Hammond et al. demonstrated a 52% same-day discharge rate, and Oxley et al. demonstrated 96% and 65% rates for planned ambulatory patients at their outpatient center and primary hospital respectively (15,44).

For autologous reconstructions, many pathways target discharge on postoperative day 3 as opposed to inpatient stays approaching 1 week in traditional literature. The ultimate goal should be safe and appropriate discharge on postoperative day 1, but to date this has only been consistently demonstrated in a highly specialized non-academic environment by Martinez and Boutros (29,41). As earlier discussed, the risk of flap-threatening complication is relatively elevated in the first 24 hours, thus true outpatient autologous reconstruction is not presently feasible. Besides the aforementioned outlier reports, 78% of examined studies reported on mean or median day of discharge, with a general range from mean day 2.6 to 4.5 and an outlier of day 6.2 from the 2015 seminal report by Bonde and colleagues (38). Just three studies, each with cohorts fewer than 100 patients, reported discharge before mean post-operative day 3 (35,43,49) while the two largest, including 204 and 198 subjects respectively, reported discharge at mean 3.2 and 3.6 days post-operatively (22,27) (Figure 4).

Figure 4 Postoperative length of stay reported in autologous reconstruction protocol studies. Y-axis depicts POD. Width indicates number of subjects included in study. Height indicates standard deviation in length of stay (days). Includes three studies reporting optimal results and the two largest included studies which reported results. From left to right: Haddock et al. 2021 (43), Jablonka et al. 2017 (49), Kaoutzanis et al. 2018 (35), Ochoa et al. 2018 (22), O’Neil et al. 2020 (27). POD, postoperative day.

Complications

An in-depth discussion of rates of adverse events after breast reconstruction and any associations with ERAS pathways is well-beyond the scope of this review. That stated, many included studies reported some metric of adverse events either inpatient or during outpatient follow-up with the majority of these showing non-significant difference between ERAS and traditional cohorts. There were three exceptions to this rule. One study, by Rochlin et al. reported significantly fewer minor complications after autologous reconstruction in the ERAS cohort and concluded that the finding may be secondary to self-resolution of issues that may have otherwise been identified during traditionally longer inpatient stays (47). Two studies reported potential concerns, with Batdorf et al. reporting significantly higher infection rates for undetermined reasons and Anolik et al. reporting significantly higher rates of symptomatic hypotension potentially secondary to under-resuscitation intraoperatively (39,46). These studies were relative outliers, and synthesis at the literature at-large demonstrates comparable outcomes at follow-up.

Considerations for implementation

The implementation of enhanced recovery protocols presents challenges consistent with previously identified barriers to compliance with medical guidelines: lack of knowledge, lack of agreement, or external factors, including institutional support and patient attitudes (97). However, there are additional unique considerations, as ERAS relies on the cooperation of various stakeholders, including surgeons, anesthesiologists, nurses, administrators and insurance providers. Kehlet et al. identified several key considerations in accounting for the multidisciplinary, multimodal, and team-based nature of ERAS. These include building multidisciplinary teams to strategize, train and implement protocols, as well as a long-term framework for feedback and assessment (98).

Multidisciplinary education and buy-in

Consistent, comprehensive education of all stakeholders has proven useful in addressing the major barriers (99-101). Emphasizing the evidence-based benefits of the protocols and aligning them when possible with existing evidence-based methodologies has resulted in greater acceptance by surgeons and anesthesiologists (102). Eliciting and incorporating feedback prior to protocol implementation facilitates understanding and addressing of perceived obstacles, resulting in more efficient implementation (103). Clear communication and networking within teams and across institutions is associated with successful outcomes, while lack of communication has been identified as one of the greatest obstacles to success (99). People tend to resist change, and in fields where ERAS represents a departure from the establishment, the presence of respected individuals across disciplines (surgeons, anesthesiologists, nurses) who are trained and invested in the protocols, helps to promote buy-in at the organizational and individual level (104-106).

Institutional support

In addition to educating stakeholders, external factors must also be considered. Securing institutional support is essential to enable successful execution of the protocols (105,107). ERAS protocols have been associated with cost optimization in terms of shorter hospital stays and fewer complications. Ensuring these financial benefits are effectively communicated to relevant stakeholders can provide a powerful incentive for their support (3,48).

Patient perspectives

Patient acceptance and perception of protocols is another consideration. Agreement has been found between patient goals and ERAS recommendations, implying that protocols should help patients achieve their preferred outcomes (108,109). Patient education regarding ERAS can provide reassurance that treatment plans align with patients’ interests and help to manage expectations accordingly. Patients have indicated the importance of consistent information and communication, with patient education and expectation setting associated with shorter hospital stays and reduced pain during recovery (40,47,101,110). Providing education in accordance with ERAS may necessitate increased time for surgical consultations, emphasizing the importance of cooperation at an institutional and individual practice level (111).

Assessment and evaluation

Finally, a structured method of evaluation and feedback is necessary to objectively assess whether goals are being met and to identify barriers and opportunities (112). Training visits and audits are an effective method for such strategic assessment (105,113,114). Programs such as the ERAS Interactive Audit System (EIAS), provide standardized data regarding outcomes across institutions, contributing to understanding the greater impact of these protocols (113).

Successful implementation of enhanced recovery protocols requires consideration of challenges to include multidisciplinary coordination and collaboration, commitment and buy-in from stakeholders, and institutional capacity and willingness to support. Proactively identifying and accounting for challenges is the first step to developing an effective ERAS implementation strategy (115).

Conclusions

There is an expansive body of literature regarding ERAS for breast reconstruction with many advancements being reported for autologous reconstruction. Implementation of effective ERAS protocols is possible and should not be viewed as excessively challenging. Moreover, enhanced recovery methods should be thought of as part of a comprehensive pathway of subsequent protocols and with multiple collaborators and stakeholders. This should include attention to optimizations from well-preoperatively to well-postoperatively with weaving of individual facets into a multimodal network (Figure 5). Of key importance throughout, is collaborative effort between specialties, staff, and hospital systems with additional emphasis on patient centered care.

Figure 5 A comprehensive enhanced recovery protocol for breast reconstruction. PO, per os; TD, transdermal; IV, intravenous; PR, per rectum; n/o, non-opioid.

Enhanced recovery after breast reconstruction has inspired innovation in the field and pushed limits previously not thought to be attainable. Enhanced recovery protocols should be considered standard of care and will serve to expand access to breast reconstruction. This is particularly true for autologous reconstructions, as these pathways are quickly moving the needle toward peri-operative outcomes consummate to those of alloplastic approaches and thus will facilitate offering of the superior approach.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Oscar J. Manrique) for the series “Breast Reconstruction” published in Annals of Translational Medicine. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-23-1509/rc

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-23-1509/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1509/coif). The series “Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. C.M.R. is a consultant for W.L Gore and Associates. A.G. serves on the board of directors of the American Board of Plastic Surgery, the California Society of Plastic Surgery, and the American Council of Academic Plastic Surgeons. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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