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Haddock et al. Plast Aesthet Res 2024;11:47 https://dx.doi.org/10.20517/2347-9264.2024.60 Page 9 of 12

Table 2. Preferred enhanced recovery after surgery (ERAS) protocol at the senior author’s institution
Phase of care Intervention
+
Planning & optimization Smoking cessation (4 wks)
+
Alcohol abstinence (4 wks)
CBC, BMP, type/screen (if Hgb < 12.5)
Referral to endocrine, PCP, cardiology when indicated
Preadmission patient education regarding the protocol per anesthesia in our presurgical testing clinic
Preoperative Antibiotics within 60 min of incision; cefazolin (or clindamycin if B-lactam allergy)
Acetaminophen 1 g PO
Celecoxib 400 mg PO
Scopolamine patch or aprepitant PO at discretion of anesthesia
NPO solids after midnight; clear liquids permitted until 2 h prior to surgery
12 oz gatorade or carbohydrate beverage on the morning of surgery
Intraoperative Induction with: lidocaine, propofol, vecuronium per anesthesia team
Dexamethasone 4-8 mg IV
Maintenance with desflurane, sevoflurane, or propofol infusion, titrated to BIS 45-55
Lidocaine infusion 1-2 mg/kg/h, stopped 30 min before liposomal bupivacaine administration
Ketamine 0.5 mg/kg bolus at induction followed by 0.2 mg/kg/h infusion or hourly bolus
Acetaminophen 1 g IV every 8 h following pre-op dose
Balanced electrolyte solution aimed at euvolemia, 1-4 mL/kg/h
Avoid use of vasopressors
Maintenance of neuromuscular blockade with vecuronium infusion
Ondansetron 4 mg IV 30 min prior to emergence
Reversal of neuromuscular blockade
Postoperative Flap monitoring every hour
Acetaminophen 1,000 mg PO, started POD 0
Encouragement of early ambulation
Early feeding: clear liquids and ice chips POD 0
Thromboprophylaxis

BID: Twice daily; BIS: bispectral index; BMP: basic metabolic panel; CBC: complete blood count; Hgb: hemoglobin; IV: intravenous; NPO: nothing
by mouth; PCP: primary care provider; PO: by mouth; POD: postoperative day; PRN: pro re nata; mg: milligram; kg: kilogram; h: hour; wks: weeks.

In the specific context of microvascular breast reconstruction, certain variables resist easy standardization.
Patient-reported outcome metrics, as exemplified by the BREAST-Q tool, contribute to standardizing the
patient’s perspective on the reconstruction process. While these metrics encompass aesthetic outcomes, they
may not entirely capture the nuanced dimensions of patient satisfaction. The aesthetic component in
microvascular breast reconstruction, integral to the patient experience, remains challenging to standardize.
Reconstructive surgeons must uphold their commitment to optimal cosmetic results, even within an
efficient procedural model. A pertinent example is presented, wherein a patient underwent bilateral DIEP
breast reconstruction in 2 h and 5 min, subsequently undergoing a single revision for skin paddle removal,
yielding an overall excellent aesthetic outcome [Figure 3].

LIMITATIONS
This systematic review was limited by the heterogeneity of the studies, the relatively low number of studies
identified that met inclusion criteria, and the overall lack of randomized controlled trials.

CONCLUSION
In summary, efficiency assumes a crucial role in microsurgical breast reconstruction, presenting an avenue
to provide high-quality care while managing costs. Embracing inventive efficiency models and refining
surgical protocols empower surgeons to improve patient outcomes, reduce complications, and secure
optimal aesthetic results. In a healthcare landscape increasingly oriented toward value-based principles,
prioritizing efficiency becomes indispensable for delivering outstanding breast reconstruction services and
enhancing the holistic patient experience.