Recommendation

Patients should receive detailed preoperative counseling.

Discussion of the surgical and anesthetic plans with the patient helps manage their expectations and concerns about the procedure. Offering patients preoperative education enables them to be a part of the decision-making process about breast reconstruction. This discussion has been shown to reduce anxiety and improve patient satisfaction independent of the reconstruction type. ^,

Recommendation

For daily smokers, 1 month of abstinence before surgery is beneficial.

For patients who are obese, weight reduction to achieve a body mass index less than or equal to 30 kg/m ² before surgery is beneficial. For alcohol abusers, 1 month of abstinence before surgery is beneficial. For appropriate groups, referral should be made to resources for these behavior changes.

Variables, such as smoking, alcohol consumption, poor nutrition, diabetes, and obesity, are some factors that are known to have an adverse effect on postoperative outcomes in breast reconstruction surgery. Patients with an active smoking history have more mastectomy flap necrosis, reconstructive failure, and higher rates of infection compared with nonsmokers. ^, Heavy alcohol consumption (defined as 5 or more drinks on each of 5 or more days in the past 30 days) has also been shown to increase the risk of surgical site infections. It is therefore recommended that patients stop smoking and drinking alcohol for at least 1 month before surgery.

Obesity (>30 kg/m ² ) is associated with flap loss and donor-site morbidity as well as increases the risk of surgical site infection and venous thromboembolism. Patients are encouraged to lose weight before surgery. In obese patients, muscle-preserving flaps (ie, deep inferior epigastric perforator [(DIEP] flap) reduce the risk abdominal wall complications, such as hernia, compared with non-muscle-sparing flaps (ie, free or pedicled transverse rectus abdominis musculocutaneous [TRAM] flap). ^,

With respect to diabetes, the National Surgical Quality Improvement Program (NSQIP) data on 29,736 women with breast reconstruction showed an increased risk of overall surgical complications (Operating room, 1.85). Poor glycemic control is associated with worse outcomes in primary closure of surgical wounds in these high-risk patients. Although not formally included in the consensus report, it has been shown that glucose levels greater than 200 mg/dL are associated with worse outcomes in terms of wound healing. Current guidelines outlined by the Society for Healthcare Epidemiology of America recommend maintaining postoperative blood glucose of 180 mg/dL or lower.

Recommendation

If preoperative perforator mapping is required, computed tomographic angiography (CTA) is recommended.

Despite risks of contrast allergy, nephrotoxicity, and exposure to radiation, modern CTA scanning protocols have been able to reduce the amount of radiation patients are exposed to. Prior metaanalysis has shown the benefits of CTA with respect to reducing operative time, postoperative flap-related complications, and donor-site morbidity compared with Doppler ultrasonography.

Recommendation

Preoperative fasting should be minimized, and patients should be allowed to drink clear fluids up to 2 hours before surgery.

A 2003 Cochrane Review of 22 randomized controlled trials showed that drinking clear fluids 2 hours before surgery is safe and does not increase the risk regurgitation and aspiration. The ERAS guidelines for gastrointestinal surgery recommend a 6-hour preoperative fasting for solid foods and 2-hour fasting for clear liquids before general anesthesia. The guidelines note that the recommendations have not been applied to patients at increased risk of gastric emptying.

Recommendation

Preoperative maltodextrin-based drinks should be given to patients 2 hours before surgery.

Studies have shown that maltodextrin-based drinks (400 mL) taken 2 hours before surgery have positive metabolic effects, such as increasing insulin sensitivity and reducing preoperative thirst and anxiety. The effect of carbohydrate loading preoperatively reduces the catabolic effects of surgery, including loss of nitrogen and protein, lean body mass, and muscle strength, resulting in a reduced length of hospital stay. Furthermore, for patients with well-controlled type 2 diabetes, a carbohydrate drink given up to 3 hours before surgery (instead of 2 hours) along with their normal medication does not delay gastric emptying and allows glucose concentrations to return to baseline.

Recommendation

Patients should be assessed for venous thromboembolism risk. Unless contraindicated, and balanced by risk of bleeding, patients at higher risk should receive low-molecular-weight heparin or unfractionated heparin until they are ambulatory or discharged. Mechanical methods (as with intermittent pneumatic compression) should be added.

Patients undergoing breast reconstruction procedures are at greater risk for venous thromboembolism. NSQIP data on 68,285 patients have shown an almost 2-fold increased risk of venous thromboembolism compared with lumpectomy or mastectomy alone (0.41% vs 0.13% and 0.29%, respectively; P <.0001). According to the American Society of Plastic Surgeons Executive Committee–approved Caprini Risk Assessment Module, patients undergoing immediate reconstruction after mastectomy meet criteria for “higher” risk of venous thromboembolism and are “highest” risk if they are obese or elderly. ^, For this population, pharmacologic anticoagulation with or without mechanical methods (ie, intermittent pneumatic compression) is recommended. ^, The ERAS guidelines recommend that prophylaxis be initiated before surgery and continue for at least 7 to 10 days. Although low-molecular-weight heparin has been shown not to increase bleeding risk in some studies, ^, other studies have shown low-molecular-weight heparin may have a higher bleeding risk than unfractionated heparin in breast surgery procedures. ^,

Recommendation

Chlorhexidine skin preparation and intravenous antibiotics covering common skin organisms should be given within 1 hour of incision.

The risk of infection following mastectomy is higher than other clean surgeries (3%–15% vs 2%). ^, This risk is further increased with the addition of a flap or prosthesis. Prophylactic antibiotics have been shown to decrease the risk of surgical-site infections. Antibiotics against common skin organisms (ie, cephalosporins) should be administered 1 hour before incision. ^, Despite the common practice of continued use of postoperative antibiotics while surgical drains are in place, prolonged use of antibiotics in breast reconstruction beyond 24 hours has not been proven beneficial in implant- and flap-based surgeries. ^, Chlorhexidine-based antiseptic skin preparations applied before surgery have been shown to decrease surgical site infections. ^,

Recommendation

Women should receive preoperative and intraoperative multimodal medications to mitigate postoperative nausea and vomiting.

Metaanalysis has demonstrated the efficacy of 5-hydroxytryptamine-3 receptor antagonists over placebo in reducing postoperative nausea and vomiting in breast surgery. Steroids alone have been shown to reduce postoperative nausea, vomiting, and pain. When combined, steroids and 5-hydroxytryptamine-3 receptor antagonists have superior effects than either alone. Preoperative neurokinin-1 receptor antagonists provide even further reduction in postoperative nausea and vomiting compared with 5-hydroxytryptamine-3 receptor antagonists.

Recommendation

Women should receive multimodal analgesia to mitigate pain.

Gabapentin has been shown to reduce analgesic requirements and pain in women undergoing mastectomy. ^, Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitor medications are effective preoperatively or intraoperatively in reducing pain without increasing bleeding complications. Bupivacaine infiltrated into the area of planned surgical incision for mastectomy is also shown to decrease pain and opiate demand postoperatively. In addition, adenosine, systemic magnesium, venlafaxine, and clonidine are also effective analgesics when administered preoperatively.

Recommendation

General anesthesia with total intravenous anesthesia is recommended for breast reconstruction procedures.

There are 3 common modalities for maintenance of anesthesia during breast surgery: general anesthesia with total intravenous anesthesia, general anesthesia with a volatile anesthetic, and regional anesthesia. Regional anesthesia, with paravertebral or transversus abdominis plane (TAP) blocks, is shown to decrease postoperative narcotic use, but does not decrease pain, nausea, sedation, time to ambulation, or length of hospital stay. General anesthesia with total intravenous anesthesia decreases postoperative nausea and vomiting compared with a volatile anesthetic in breast surgery. ^,

Recommendation

Preoperative and intraoperative measures, such as forced air, to prevent hypothermia should be instituted. Temperature monitoring is required to ensure the patient’s body temperature is maintained higher than 36°C.

The Surgical Care Improvement Project found an association with hypothermia and impaired wound healing, prolonged hospitalization, and a 3-fold higher wound infection risk. Maintaining patient temperature higher than 36°C reduces multiple complications, including cardiac conditions, altered drug metabolism, as well as decreased wound infections. Preoperative patient-warming strategies affect intraoperative warming strategies, so warming an operating room will not be sufficient to prevent hypothermia. In a systematic review of multiple randomized controlled trials, forced-air warming is safe and effective in preventing hypothermia. Warmed intravenous fluid reduces hypothermia for short procedures, but in longer surgeries, it is insufficient.

Recommendation

Overresuscitation or underresuscitation of fluids should be avoided, and water and electrolyte balance should be maintained. Goal-directed therapy is a useful method to achieve these goals. Balanced crystalloid solutions rather than saline is recommended. Vasopressors are recommended to support fluid management and do not negatively affect free-flap breast reconstruction.

Overresuscitation can affect cardiopulmonary events and wound infection and can increase wound-healing problems and length of hospital stay. ^, Both overresuscitation and underresuscitation have been shown to increase the risk of anastomosis thrombosis in free-flap breast reconstruction. ^, Historically, vasopressors used to maintain blood pressure have been avoided in flap patients, but studies have shown that they are safe to use in normovolemic patients. Balanced crystalloid solutions are shown to be superior to 0.9% saline for maintaining electrolyte balance.

Recommendation

Multimodal postoperative pain management regimens that are opioid sparing should be used with the goal of facilitating early mobilization.

Consideration to reducing opioid use after surgery can help alleviate some of the effects of postoperative nausea and vomiting, as well as constipation. According to Cochrane data from randomized controlled trials, the combination of acetaminophen and NSAIDs is more effective than either alone. Multiple randomized controlled trials further demonstrate that NSAIDs reduce the need for narcotics with minimal surgical site bleeding risk. A metaanalysis of randomized controlled trials showed that ketorolac does not increase perioperative bleeding. Gabapentin administered preoperatively or postoperatively is effective for pain control and also demonstrates reduced narcotic requirements. ^,

The use of regional or local blocks can help minimize pain, narcotic use, and sedation. Paravertebral blocks with continuous bupivacaine infusion catheters have been shown to reduce opioid requirements, ^, and TAP blocks have been effective in decreasing abdominal donor site pain in flap patients.

Recommendation

Patients should be encouraged to take fluids and food orally as soon as possible, preferably within 24 hours after surgery.

Early refeeding within 24 hours after surgery is safe and associated with improved healing, reduced infection, and reduced hospital stay. The decision of when to resume a diet after surgery should be weighed against the risk of a possible urgent return to the operating room, for example, in patients who develop a microvascular thrombosis in their free-flap reconstruction. ^, Rapid-sequence intubation can help mitigate the risk of aspiration in the event of an urgent return to the operating room.

Recommendation

Flap monitoring within the first 72 hours should occur frequently. Clinical evaluation is sufficient for monitoring, with implantable Doppler recommended in cases of buried flaps.

Microvascular thrombosis of the free flap occurs in 2% to 5% of cases and typically within the first 72 hours. ^{, ,} In most cases (60%–74%), thrombosis occurred in the venous system. ^, Studies have shown that the outcomes are improved in earlier salvage interventions in a compromised free flap. ^, Monitoring of flaps includes clinical observation for color, temperature, and capillary refill, as well as the use of monitoring devices. The hand-held Doppler is a noninvasive adjunct to clinical observation and is shown to be highly effective in monitoring free flaps. The typical protocol is 1-hour monitoring in the first 24 hours, every 2 hours for the next 24 hours, and then every 3 to 4 hours for the next 24 hours.

Implantable Doppler devices have excellent sensitivity in detecting flap compromise, but may detach and result in a higher false-positive rate than clinical observation. Clinical observation with or without implantable Doppler monitors has equivocal rates of flap salvage. ^, In the case of buried flaps, implantable Doppler is the only objective measure. Alternative flap monitoring devices include a venous coupler with an embedded implantable Doppler device, laser Doppler monitoring, infrared spectroscopy, tissue oximetry, and microdialysis.

Recommendation

For incisional closure, conventional sutures are typically recommended. Complex wounds following skin necrosis are treatable with debridement and negative pressure wound therapy.

Typically, breast and abdominal incisions following breast reconstruction are closed with layered intradermal absorbable sutures. Skin adhesive octyl-2-cyanoacrylate is widely used in breast surgery and shows patient preference but no objective difference in cosmesis or complications. The length of time for a dressing to stay in place is variable. A clinical trial comparing dressing removal at day 1 versus dressing removal at day 6 is ongoing. Preliminary results may support standard recommendations of dressing removal after breast reconstruction in 24 to 48 hours.

Regarding complex wounds associated with mastectomy flap, DIEP flap and abdominal skin necrosis are known possible complications of breast reconstruction. ^, Surgical debridement and negative-pressure wound therapy is an effective adjunct in wound management, with studies showing complete healing in 97% of breast wounds.

Recommendation

Patients should be mobilized within the first 24 hours after surgery.

Prolonged inactivity combined with a catabolic state (ie, postoperative stress) exacerbates muscle atrophy. Early mobilization of patients improves muscle strength and reduces risk of pulmonary embolism, pneumonia, and decubitus ulcers. In addition, early mobilization decreases length of hospital stay and improves overall psychological well-being.

Recommendation

Early physiotherapy, supervised exercise programs, and other supportive care initiatives should be instituted after discharge.

For patients undergoing mastectomy and axillary dissection, early physical rehabilitation has been shown to improve physical and emotional recovery. ^, Physical rehabilitation programs in the postoperative period improve mobility, decrease pain, and enhance quality of life for patients with breast cancer. Visiting nurses also provide an important role in delivering physical care and education, as well as psychosocial support following TRAM flap reconstruction.