Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

Abstract

Background Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. Methods Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. Results A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. Conclusion Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis

“…In parallel, this has gradually permitted us to expand our autologous breast reconstruction practice to offering other flaps such as a variety of conjoined and stacked flaps, PAP flaps, and LAP flaps. 12–21…”

“…In parallel, this has gradually permitted us to expand our autologous breast reconstruction practice to offering other flaps such as a variety of conjoined and stacked flaps, PAP flaps, and LAP flaps. [12][13][14][15][16][17][18][19][20][21] For clinical relevancy, we divided the cohort into four groups based on quartile OT values rounded to the nearest hour. This resulted in four-time intervals that were similar in size (each between 23% and 27% of the total population).…”

The profunda artery perforator flap for upper limb reconstruction: A case report and literature review on the flap applications in reconstruction

“…Originally the PAP flap was described as a pedicled option for ischiatic pressure sores (Arquette et al, 2022 ; Homma et al, 2001 ; Kim et al, 2014 ; Lee et al, 2009 ; Sharp et al, 2021 ) and as a free flap for head and neck reconstruction, including tongue (Heredero et al, 2021 ; Riera et al, 2017 ; Scaglioni et al, 2015 ). A recent expanding use is for breast reconstruction (Ahmadzadeh et al, 2007 ; Allen et al, 2012 , 2016 ; Angrigiani et al, 2001 ; Atzeni et al, 2021 ; Cho et al, 2021 ; Jo et al, 2022 ; Martinez et al, 2021 ; Murphy et al, 2021 ; Saad et al, 2012 ; Song et al, 2020 ; Yano et al, 2020 ). Murphy et al ( 2021 ) demonstrated the superiority of the PAP flap compared to the IGAP flap as alternative option to the DIEP flap in breast reconstruction.…”

“…The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction Filippo Boriani and Paolo Sassu equally contributed to the idea, the development and the editing of the study. (Atzeni et al, 2021;Cho et al, 2021;Ciudad et al, 2022;Heredero et al, 2021;Jo et al, 2022;Karakawa, Yoshimatsu, Fuse, et al, 2020;Kehrer et al, 2018;Martinez et al, 2021;Murphy et al, 2021). Historically, based on proximal musculocutaneous perforators from the adductor magnus (AM) muscle, it was initially referred as "adductor flap" by Angrigiani et al (2001).…”

Comparative Study of DIEP and PAP Flaps in Breast Reconstruction: Reconstructive Outcomes and Fat Necrosis

“…3,4 The PAP flap is particularly advantageous in slim patients who would not want an abdominal scar, prefer a hidden scar, and lower donor site morbidity. 5,6 The PAP flap is anatomically consistent with a pedicle length of approximately 10 cm, which is greater than that of the transverse upper gracilis (TUG) flap. 7 Previous studies on PAP flap breast reconstruction have focused on the technical issues associated with the surgical procedure, anatomy, and donor site morbidity, [8][9][10] and have reported that the success rate does not differ from that of the DIEP flap.…”