Page 81 - Read Online

Page 8 of 12 Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60

is divided into quantifiable steps: recipient site preparation, DIEP flap dissection and harvest, microsurgery,
aesthetic breast inset and shaping, and abdominal closure. Video instruction on recipient site preparation
[49]
was published and used to instruct the junior members of the team . With the implementation of this
deliberate practice, our institution has reduced operative time for bilateral DIEP flap breast reconstruction
to an average of less than 4 h.

Our practice adheres to the principle of each site being its own independent operation. With that in mind,
the operative field is prepared with each site (left and right breast, left and right abdomen) having its own
electrocautery machine, including Bovie electrocautery and bipolar forceps. Other time-saving measures
include the use of a venous coupler for all venous anastomoses, umbilectomy and placement of progressive
tension sutures for the abdominal donor site, and placement of a single abdominal drain. Of note, the near-
universal umbilectomy is a result of critical evaluation of postoperative results. We noticed a relatively high
number of umbilical wound complications. By eliminating the umbilicus, we reduced wound complications
but subsequently noted an increased frequency of seroma formation. Hence, the addition of progressive
tension sutures has reduced complication rates to at or below those reported in the literature. Additionally,
this allows better control of muscle plication, scar placement, and ultimately, neoumbilicus placement.

Perfusion evaluation is commonly employed through a variety of methods and is supported in the
literature [50-52] . Most commonly, and perhaps the gold standard, is direct visualization of bleeding dermis
upon de-epithelialization of the flap during inset. Since the borders of the flap are almost always buried (and
therefore de-epithelialized), a healthy bleeding dermis confirms perfusion of all aspects of the flap. In cases
where there is questionable perfusion or concern for anastomotic complications, fluorescent angiography
with indocyanine green (ICG) dye is used. A retrospective review of 500 flaps at our institution showed that
employing ICG for evaluation of flap perfusion decreased rates of postoperative fat necrosis and reduced
resection volumes compared to controls .
[53]
Postoperative
As stated earlier, the primary goal of value-based healthcare is improving patient outcomes while decreasing
“inputs” to the system, usually by decreasing costs. Regarding MABR, several institutions have reported safe
outcomes for postoperative day 1 (POD1) discharge after bilateral DIEP flap breast reconstruction [54-56] .
Reducing operative time has significant downstream effects, including reducing anesthesia time, initiating
the recovery process sooner, and advancing through recovery stages more quickly. In a theoretical 10-hour
case, the recovery process would not begin until 7:00 p.m., and many patients are not allowed a regular diet
until the next morning when they are outside of the 24-hour postoperative window. When reducing
operative times to 4 h or less, the recovery process obviously begins much sooner, making a POD1
discharge feasible.

Enhanced Recovery After Surgery (ERAS) pathways have been popularized across all surgical fields,
including MABR. The primary goal of these protocols is to facilitate patient recovery, reduce narcotic use,
and promote earlier discharge from the hospital. It is typically initiated preoperatively and continued until
discharge for maximal effect . Preoperative factors include the administration of celecoxib and
[57]
acetaminophen, as well as allowing patients to drink 12 ounces of an electrolyte-rich carbohydrate beverage.
Intraoperative application of liposomal bupivacaine in regional field blocks provides enhanced analgesia.
Intravenous steroids and ondansetron, as well as a scopolamine patch, may be useful for reducing
postoperative nausea. Postoperatively, patients are encouraged to ambulate early, potentially on the same
day of surgery [Table 2].