Plastic Surgery Research Council

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Post-Operative Protocol for Autologous Free Flap Breast Reconstruction Optimizing Resources and Patient Safety
Allison Haley, B.S., Tobias J. Bos, B.Sc., Brian H. Cho, M.D., Deepa Bhat, M.D., Hannah M. Carl, B.S., Benjamin Ostrander, B.S., Michele A. Manahan, M.D., Gedge D. Rosson, M.D., Justin M. Sacks, M.D., M.B.A., F.A.C.S..
Johns Hopkins University, Baltimore, MD, USA.

PURPOSE: There are multiple post-operative protocols in the literature for autologous free flap breast reconstruction patients. Commonly, this demographic of patients can be admitted to the intensive care unit (ICU) postoperatively for close monitoring of flap viability and then be subsequently transferred to a general surgical floor prior to discharge. With the advent of devices that enable continuous tissue-oximetry monitoring, it may no longer be necessary for these patients to go to the ICU post-operatively. We aim to show that our three-day post-operative protocol not only maintains excellent clinical outcomes, but is also more cost and resource effective than protocols with longer length of stay (LOS) or overutilization of the ICU.
METHODS: Current literature was reviewed for validation of tissue oximetry use in free flap monitoring. Costs for our post-operative pathway were collected from the Department of Plastic and Reconstructive Surgery. We abstracted demographics, LOS and short-term complications on all consecutive patients who underwent autologous free flap breast reconstruction at our institution from January 2013 to August 2014. Our complication rates were then compared to those in the literature.
RESULTS: We reviewed 153 consecutive patients with a total of 239 free flaps using our post-operative protocol. The mean age was 50 years (SD=10.2) and mean body mass index (BMI) was 29.4 (SD=5.2). Our institution's rate of flap failure was not significantly different from the published national rate (p=0.367). Unplanned reoperation was significantly lower than the published national rate (p<0.001). Patients are cared for immediately on the general surgical floor, which costs $1827/day compared to the national average for monitoring a non-mechanically ventilated patient in the ICU of $6667/day. We use one tissue oximetry probe per free flap, which cost $713 each. 71% of patients are discharged on or before POD 3. Patients who are discharged after POD 5 were due to complications, including pulmonary embolism, infection and deep vein thrombosis. Our protocol has been standard of care for over 12 years. Assuming discharge on POD 3, spending the first 24 hours in the ICU would cost $4,315, while sending patients directly to the surgical floor would cost $3,262, resulting in a savings of over $1,000 per bilateral reconstruction.
CONCLUSION: The autologous breast reconstruction post-operative protocol initiated by our institution is more cost and resource effective than protocols utilizing the ICU and higher levels of patient monitoring. Immediate post-operative care on a general surgical floor with tissue oximetry does not increase the risk of flap failure or unplanned reoperation. Our protocol serves as a streamlined approach that allows reallocation of valuable resources, specifically ICU utilization, and minimizes healthcare costs without compromising patient safety. This protocol should therefore be considered for adoption at institutions where autologous free flap breast reconstruction is performed.


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