Purpose: Flap loss due to microvascular compromise remains an uncommon but dreaded complication in autologous breast reconstruction. Prompt identification of microvascular compromise and rapid return to the operating room are associated with higher rates of flap salvage. At our institution, we utilize an enhanced recovery after surgery (ERAS) protocol for autologous breast reconstruction with anticipated discharge on postoperative day three. Due to the high cost of prolonged hospital admission, there has been renewed interest in strategies to expedite discharge following autologous breast reconstruction. We sought to characterize the timing of microvascular compromise to guide patient counseling and minimize the risk of flap loss in the face of increasingly early hospital discharge. 

 

Methods: A retrospective review of 338 patients (540 breasts) who underwent autologous breast reconstruction from 2017-2021 was conducted at a single institution. The incidence of arterial or venous compromise, time to flap compromise, return to the operating room for flap revision, rate of flap loss, and length of stay were reviewed. 

 

Results: There were 10 (1.9%) cases of microvascular compromise, including 3 (0.6%) cases of arterial compromise, 6 (1.1%) cases of venous compromise, and 1 (0.2%) case of combined arterial and venous compromise. A total of 9 patients (2.7%) experienced microvascular compromise requiring return to the operating room. Time to flap compromise ranged from 1 – 86 hours postoperatively, with most cases (80%) occurring within 24 hours postoperatively. Among patients who experienced flap compromise, length of stay ranged from 3 – 7 days postoperatively from the index operation. There were 2 (0.4%) cases of total flap loss, which occurred at 60 and 86 hours postoperatively. Among those cases of flap loss, one was later reconstructed with a latissimus dorsi flap and the other was reconstructed with a breast implant, respectively. 

 

Conclusions: The incidence of microvascular compromise in our cohort was low (1.9%). All but 2 cases of microvascular compromise occurred within 24 hours postoperatively. These findings suggest that for most patients, discharge prior to postoperative day three is safe and could reduce hospital length of stay.