Autologous can be Ambulatory: The Outpatient Latissimus Flap for Breast Reconstruction
Haripriya Ayyala, MD1, Thuy-My Le, MSE1, Stephanie Cohen, MD2.
1Rutgers-NJMS, Newark, NJ, USA, 2Hackensack-University Medical Center, Hackensack, NJ, USA.
BACKGROUND: The latissimus dorsi myocutaneous flap is an excellent autologous option for breast reconstruction, but traditionally results in an inpatient hospital stay, increasing costs and risks for complications. The authors aim to demonstrate that the latissimus flap can be safely performed in an ambulatory setting for breast reconstruction. METHODS: All cases of outpatient latissimus flap for breast reconstruction by the senior surgeon (S.C.) were reviewed. Pre-operatively, patient expectations for outpatient surgery were set at time of informed consent, including review of post-operative pain prescriptions and drain care. Intra-operatively, liposomal bupivacaine was infiltrated at surgical sites. Demographics, operative time, time in recovery room, use of narcotics intra-operatively and post-operatively, and complications were evaluated. Cost estimates were created using previously published data. RESULTS: 14 outpatient latissimus flaps were performed successfully in 13 patients with immediate silicone implant placement. Average age was 55 and average BMI 27.1. 10/14 (71%) breasts were previously radiated, and all flaps were performed as delayed reconstruction. Average operating time was 3 hours, 25 minutes. Pre-operatively, all patients received IV acetaminophen. Intra-operatively, all patients received fentanyl (mean 242 mcg); 6/14 (43%) received ketorolac and 2/14 (14%) received hydromorphone. In the recovery room, only 7/14 (50%) utilized narcotic pain medication. Patients were discharged after an average stay in the recovery room of 3 hours, 25 minutes with prescriptions for ketorolac and tramadol. No patients required inpatient admission for pain control or complications and no patients required additional refills of controlled substance pain medications. There were no major complications; 3/14 (21%) of patients developed a seroma at the donor site which resolved without operative intervention or aesthetic deformity. The cost savings by avoiding an inpatient stay averaged $19,854. CONCLUSIONS: The latissimus dorsi myocutaneous flap for breast reconstruction can be safely performed on an outpatient basis with potential for benefits in surgical outcomes and cost efficacy. In addition, avoiding an inpatient stay can have a tremendous positive emotional impact on patients, many of whom may have already experienced delays or complications in their reconstructive pathway. Addressing pain through multimodal analgesia and robust preoperative education programs are integral to the success of ambulatory autologous breast reconstruction.
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