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Background:. The National Surgical Quality Improvement Program (NSQIP) database provides an important resource for determining complication rates and risk factors for surgical procedures. However, NSQIP is limited to 30-day follow-up, and it is unclear whether this is reliable for evaluating prosthetic breast reconstruction outcomes. Methods:. A single-institution, cross-sectional, retrospective review was performed for patients undergoing mastectomy with immediate, prepectoral tissue expander reconstruction. Timing of complications was stratified as early (within 30 days of operation) versus late (after 30 days). Categorical variables were compared using χ2 (or Fisher exact) tests, and continuous variables were analyzed using Kruskal-Wallis or Wilcoxon rank-sum tests. Results:. There were 301 patients (509 reconstructed breasts) included with a median follow-up time of 11 months. Of them, 176 patients (58%) experienced a postoperative complication—140 patients (47%) experienced an early complication and 36 patients (12%) experienced a late complication. Patients with late complications had a significantly higher rate of reconstructive failure compared with the early complication group (17% versus 10%; P = 0.001) and were more likely to require a flap (28% versus 7%; P = 0.001) for final reconstruction. Revision surgery rates after final implant placement were higher in the late complication group (36% versus 64%; P = 0.285). Conclusions:. Late complications after prepectoral breast reconstruction have a more prominent impact on reconstructive failure and revisions than early complications. This finding may inform strategies to revise national databases such as NSQIP to include more detailed information and longer capture periods.

Background:. Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS’s impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods:. Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results:. In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0–2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions:. Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.

Background:. Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods:. The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results:. The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0–3; however, this finding was not statistically significant. Conclusion:. Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.