Prepectoral Placement of Tissue Expanders Affects Inpatient Opioid Use
Halley Darrach, Franca Kraenzlin, MD, Nima Khavanin, MD, Justin M. Sacks, MD MBA.
Johns Hopkins School of Medicine, BALTIMORE, MD, USA.
BACKGROUND: Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease 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 opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. Our hypothesis was prepectoral tissue expander placement following mastectomy will lead to reduced narcotic requirements in the inpatient and outpatient setting.
METHODS: A retrospective review was performed of patients 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 [OME]), and discharge prescriptions.
RESULTS: Two hundred and thirty-one patients were identified (mean age 48.8 years), of whom 94 underwent subpectoral and 137 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid naïve. The rate of bilateral procedures did not differ between cohorts (p=0.490). Overall, 92% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (p=0.0891). Two subpectoral and two prepectoral patients required prolonged admission due to post-operative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an “as needed” (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs. 44.5 OME, p=0.0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs. 336.99 subpectoral, p=0.3197).
CONCLUSIONS: Prepectoral expander placement appears to be associated with decreased opioid use post-operatively within the inpatient setting. Outpatient narcotic usage was unchanged but this could be related to dogmatic prescription practices. This study did not investigate specifically clinical outcomes, however, decreased opioid requirements for the prepectoral placement of tissue expanders following mastectomy perhaps represents an opportunity to improve overall patient outcomes. Further research comparing aesthetic and functional outcomes of this procedure are warranted.
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