Nuances of Postoperative Management of Microvascular Breast Reconstruction Patients: Where Are the Data? (2019)

Sir: Postoperative management schemes for microsurgical breast reconstruction are often dominated by standardized order sets filled with “clinical gestalt,” including those of our own institution: a tertiary medical center performing a high-volume of microsurgical breast reconstruction. Postoperative orders include (but are not limited to) the following: Bair Hugger (3M, St. Paul, Minn.) at all times, restriction of caffeine and chocolate, maintaining the patient’s room temperature above 75°F, daily aspirin administration, frequent flap checks, and daily antibiotics until discharge. Many of these orders stem from anecdotal evidence that exists simply because “That’s how we did it where we were trained.” In an attempt to standardize our order sets based on evidence, we sought to perform a systematic review of the available literature on the nuances of postoperative management of microvascular breast reconstruction. Search was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines with MEDLINE, Web of Science, and the Cochrane database.1 Search terms included free flap OR microsurgery OR free tissue AND breast reconstruction, with additional terms “management,” “postoperative,” and “perioperative.” Further searches were performed to include “caffeine,” “chocolate,” and “room temperature.” After duplicates were removed, 1338 articles were screened by title, and of those, 210 full-text articles were assessed for eligibility. A total of 110 were then excluded, as they were not limited to breast reconstruction, did not include a description of postoperative management, were commentary or review articles, or were non-English language studies. This left a total of 100 articles from 1989 to the present. Of these, only seven were randomized controlled trials, and 10 were prospective cohort studies. The remaining 83 articles were composed of retrospectively completed cohort and case-control studies and case series, written in the “how I do it” style, most often detailing a single-surgeon or single-hospital experience with microsurgical breast reconstruction over many years.2,3 Postoperative management topics discussed included anticoagulation, antibiosis, flap monitoring, intravenous fluid management, catheter and suction drain use, diet advancement, mobilization, pain control, and transfusion thresholds. Notably, there was a wide variation in the depth at which these topics were discussed, ranging from a single sentence to a detailed description of one or two aspects of postoperative management. Flap monitoring was the most frequently reviewed postoperative management topic, discussed in some capacity in 59 articles (59 percent).4 The majority of studies in which flap monitoring was discussed were retrospective case series, whereas pain control was the subject of the majority of the randomized controlled trials [n = 5 (71 percent)].5 Based on this literature review, high-level evidence seems to be lacking for the more anecdotal features of postoperative management of microvascular breast reconstruction which, given the complexity and high-stakes nature of these patients, is not surprising. However, this fact makes it difficult not only to abandon old habits but also to adopt novel management strategies that have the potential to improve patient outcomes and reduce cost. Until we generate the high-level evidence required to better guide management, non–evidence-based methods will likely predominate, and we will continue with current strategies because “That’s how we did it where we were trained.” DISCLOSURE The authors have no financial interests to disclose. Carol E. Soteropulos, M.D.Sherry Y. Q. Tang, B.S.Samuel O. Poore, M.D., Ph.D.Division of Plastic and Reconstructive SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadison, Wis.