ORIGINAL ARTICLE BREAST SURGERY
Enhanced Reco e y A e Su ge y (ERAS) Pa hways o Aes he ic
B eas Su ge y: A P ospec i e Coho S udy on Pa ien -Repo ed
Ou comes
S e
´phane S ahl
1
•Adelana San os S ahl
1
•You-Shan Feng
2
•A ne Es le
3
•
Flo ian Buiculescu
1
•Ana C is ina Seab a Robalo Gomes Jo ge
4
Recei ed: 30 Ma ch 2023 / Accep ed: 23 Ap il 2023
The Au ho (s) 2023
Abs ac
Backg ound Pa ien s’ expec a ions o an an icipa ed
imeline o eco e y and ea o anes hesia in aes he ic
b eas su ge y ha e no been s udied.
Objec i e This s udy aims o assess pa ien anxie y,
expec a ions, and sa is ac ion a e Enhanced Reco e y
a e Su ge y (ERAS) pa hways o aes he ic b eas su ge y
and he p og ess o pos ope a i e eco e y.
Ma e ials and me hods All consecu i e pa ien s who
unde wen aes he ic b eas su ge y be ween Ap il 2021 and
Augus 2022 we e included in his single-cen e p ospec-
i e coho s udy. The ERAS p o ocol consis s o mo e han
20 indi idual measu es in he p e-, in a-, and pos ope a i e
pe iod. Epidemiological da a, expec a ions, and eco e y
we e sys ema ically assessed wi h s anda dized sel -
assessmen ques ionnai es, including he In e na ional Pain
Ou come Ques ionnai e (IPO), he BREAST-Q o BODY-
Q, and da a collec ion o ms.
Resul s In o al, 48 pa ien s wi h a median o 30 yea s o
age we e included. Pa ien s e u ned o mos daily ac i i ies
wi hin 5 days. Eigh y-eigh pe cen o pa ien s we e able o
accomplish daily ac i i ies soone han expec ed. The ime
o e u n o no mal daily ac i i ies was simila ac oss all
p ocedu e ypes. The e was no s a is ically signi ican di -
e ence ega ding pos ope a i e sa is ac ion be ween
pa ien s who eco e ed slowe (12%) and pa ien s who
eco e ed as as o as e (88%) han an icipa ed
(p=0.180). Pa ien s epo ing ea o anes hesia in he o m
o conscious seda ion signi ican ly diminished om 17 o
4% pos ope a i ely (p 0.001).
Conclusion Enhanced Reco e y a e Su ge y (ERAS)
pa hways o aes he ic b eas su ge y a e associa ed wi h
apid eco e y and high pa ien sa is ac ion. This su ey
s udy p o ides aluable insigh in o pa ien s’ conce ns and
pe spec i es ha may be implemen ed in pa ien educa ion
and consul a ions o imp o e pa ien sa is ac ion ollowing
aes he ic ea men s.
Le el o E idence IV This jou nal equi es ha au ho s
assign a le el o e idence o each a icle. Fo a ull
desc ip ion o hese E idence-Based Medicine a ings,
please e e o he Table o Con en s o he online
Ins uc ions o Au ho s www.sp inge .com/00266.
Keywo ds Fas - ack su ge y Fas eco e y su ge y 
Enhanced eco e y su ge y B eas augmen a ion ERAS 
Ou pa ien su ge y
In oduc ion
The e is an e e -inc easing p essu e o pe o m su ge ies in
he ambula o y se ing, p ima ily o imp o e cos -e ec-
i eness. This end has been ein o ced by he COVID-19
pandemic [1]. Many s udies ha e documen ed he sa e y
and easibili y o ambula o y b eas su ge y in selec ed
pa ien s. Mos o hese s udies ha e ocused on ou comes,
namely complica ions and eadmissions [2,3].
&Ana C is ina Seab a Robalo Gomes Jo ge
[email p o ec ed]
1
Cen e Plas p i a e p ac ice, Bahnho s aße 36, 66111
Saa b u
¨cken, Ge many
2
Ins i u e o Clinical Epidemiology and Applied Biome ics,
Medical Uni e si y o Tu
¨bingen, Tu
¨bingen, Ge many
3
Depa men o Diagnos ic and In e en ional Radiology,
Uni e si y Hospi al o Tu
¨bingen, Tu
¨bingen, Ge many
4
Depa men o Gene al, Visce al, Vascula , and Pedia ic
Su ge y, Saa land Uni e si y Hospi al, Ki be ge S aße,
66421 Hombu g/Saa , Saa land, Ge many
123
Aes h Plas Su g
h ps://doi.o g/10.1007/s00266-023-03392-1
Unde s anding ac o s ha enhance eco e y and pa ien
com o , and inc ease pa ien sa is ac ion is a equisi e o
main aining a success ul p ac ice. Enhanced Reco e y a e
Su ge y (ERAS), also known as as - ack su ge y (FTS),
consis s o in e disciplina y mul imodal pe iope a i e
in e en ions aimed o op imize he eco e y p ocess,
including educing hospi al s ay o a oiding hospi aliza-
ion. The bene i s o ERAS p o ocols ha e been s udied in
a ious su gical subspecial ies [4]. Al hough esea ch
aiming a educing opioid consump ion and hospi al s ay
da es o he 1990s, he e m ‘‘enhanced eco e y a e
su ge y (ERAS)’’ has no gained much a en ion in cos-
me ic plas ic su ge y [5]. Li le esea ch has been done
ega ding unc ional eco e y o pa ien s a e aes he ic
b eas su ge y [6].
Pa ien sa is ac ion a e su ge y co ela es wi h he
ul illmen o pa ien s’ p esu gical expec a ions [7]. Un e-
alis ic expec a ions p edic an unsa is ac o y ou come [8].
Pa ien s belie e ha anes hesia and eco e y a e ela i ely
simple and, he e o e, es ic ion o ac i i ies a e aes he ic
su ge y is no necessa y [9,10]. Di e gence be ween ac ual
expe ience and expec a ions impac s ea men adhe ence
and he pa ien s’ sa is ac ion [11]. Only one s udy exam-
ining pa ien sa is ac ion wi h pos ope a i e eco e y was
iden i ied in a sys ema ic e iew o pa ien - epo ed ou -
comes ollowing cosme ic su ge y [12]. This gap o
knowledge may lead physicians o unde alue he aspec s
o eco e ing.
This s udy’s objec i e is o in es iga e a) pa ien s’
expec a ions abou eco e y imelines as well as conce ns
be o e unde going aes he ic b eas su ge ies wi hou gen-
e al anes hesia and b) o e alua e eco e y and sa is ac ion
a e enhanced ERAS pa hways o aes he ic b eas
su ge y.
Ma e ial and Me hods
Pa ien s
The local E hics Commi ee ga e hei pe mission o his
p ospec i e s udy (p ojec no. 144/21). In o med consen
o p ospec i e analysis was ob ained. All consecu i e
pa ien s who unde wen aes he ic b eas su ge y om Ap il
2021 o Augus 2022 we e included in his s udy. Unde age
pa ien s and pa ien s equi ing e ision su ge ies wi hin he
i s week we e excluded, as we e pa ien s wi h incomple e
sel -assessmen ques ionnai es o incomple e clinical s udy
epo s. The ERAS p o ocol and anes hesia was pe o med
as p e iously desc ibed by he au ho s [13]. All pa ien s
ecei ed 1000 mg ace aminophen and 1000 mg anexamic
acid PO 2 h be o e su ge y, as well as dexame hasone
4 mg IV be o e s a ing he su ge y (Table 1).
The au ho s desc ibed p eope a i e counseling explici ly
in p e iously published wo k [13]. Pa ien s engaged in
minimal wo k- ela ed physical ac i i y and we e ad ised o
ake 7 days o wo k. Re u n o mode a e ae obic physical
ac i i y o s enuous a m wo kou was discou aged be o e
he i h pos ope a i e week. Comp ehensi e pe iope a i e
ins uc ions we e a ached o he in o med consen o m
and sen ia e-mail be o e su ge y.
Su ge y and Loco egional Anes hesia
All in e cos al blocks we e pe o med wi h opi acaine
0.375%, 4 mg o dexame hasone, and epineph ine
(1:100.000). Immedia ely a e seda ion, he su geon
injec ed 5 ml in he subcos al egion o in e cos al block
be ween he hi d and he se en h ibs in a s anda d ashion
[14]. Fo hemos asis and local anes hesia, lidocaine 0.1%
wi h epineph ine (1:500.000) was injec ed in o he incision
si es (Table 1), obse ing p e iously desc ibed maximum
dosages o 28 mg/kg [15]. Ten minu es a e su ge y,
pa ien s we e allowed o d ink and, in he absence o
nausea, o ea a e wa d. Pa ien s we e gi en pe mission o
discha ge a e su ge y i hey ole a ed ood, could u ina e,
walk alone, had no unbea able pain, and had no nausea.
Pa ien s we e eques ed o ha e he assis ance o a ca e-
gi e a home on he i s nigh . Pa ien s ecei ed a dis-
cha ge le e including pos ope a i e ins uc ions, ollow-
up appoin men s, and he su geons’ cell phone numbe .
The su geons made a pos ope a i e ollow-up phone call
la e he same day.
Ques ionnai es and Clinical S udy Repo s
Clinical s udy epo s we e designed in ol ing all membe s
o he eam as easy- o-use da a collec ion o ms wi h su -
icien and unambiguous da a. Sa is ac ion wi h he ope -
a i e esul was assessed wi h he BREAST-Q
Augmen a ion, BREAST-Q Reduc ion/Mas opexy, o
BODY-Q Ches module. Anxie y and sa is ac ion ega d-
ing anes hesia we e assessed wi h 5 i ems om he ali-
da ed In e na ional Pain Ou come Ques ionnai e (IPO)
[16]. I ems om he Wo ld Heal h O ganiza ion (WHO)
In e na ional Classi ica ion o Func ioning, Disabili y, and
Heal h (ICF) we e chosen based on expe opinions and
li e a u e esea ch [17,18]. The de elopmen o he ques-
ionnai e has been desc ibed elsewhe e [13]. P ima y and
seconda y ou come pa ame e s and iming o assessmen s
we e:
123
Aes h Plas Su g
•S uc u ed sel -assessmen ques ionnai e o demo-
g aphic da a (gende , age, BMI, como bidi ies, medi-
ca ion, and ASA sco e) comple ed be o e he i s
consul a ion.
•Pa ien - epo ed anxie ies and sa is ac ion ega ding
anes hesia we e assessed by he IPO adminis e ed
be o e and he day a e su ge y.
•Pa ien - epo ed an icipa ed and ac ual eco e y in he i s
pos ope a i e week was assessed wi h a sel -assessmen
ques ionnai e be o e and 10 days a e su ge y.
•Clinical s udy epo s wi h desc ip i e da a ega ding
su ge y and anes hesia we e assessed on he ope a ion
day by he ci cula ing nu se.
•Pa ien - epo ed sa is ac ion wi h he ope a i e esul
was assessed wi h he BREAST-Q Augmen a ion,
BREAST-Q Reduc ion/Mas opexy o BODY-Q Ches
module adminis e ed be o e he i s consul a ion and a
leas 4 weeks pos ope a i ely.
S a is ics
Fo con inuous a iables wi h a no mal dis ibu ion, he mean
and s anda d de ia ion (95% con idence in e al) a e p esen ed,
whe eas o non-no mal da a, he median and in e qua ile
ange. The s a is ical analyses we e ca ied ou wi h SPSS
Ve sion 28 (SPSS Inc., Chicago, Illinois, USA). The co ela-
ions be ween he a ious pa ame e s we e e alua ed using a
Spea man co ela ion ma ix. PB0.05 was used o de ine sig-
ni icance. We used he Wilcoxon ank-sum es o access g oup
di e ences ac oss nonpa ame ic a iables.
Resul s
No pa ien d opped ou , wo we e excluded due o ope a-
i e e ision, and one because o an incomple e ques ion-
nai e. Fo y-eigh pa ien s wi h a median (IQR) o 30
Table 1 Anes he ic p o ocol
Timing Anes he ic p o ocol
P eope a i e A leas 2 appoin men s o comp ehensi e p eope a i e counseling
Pe iope a i e ins uc ions a ached o he in o med consen o m and sen ia e-mail be o e su ge y
Chlo hexidine showe ing on he day o su ge y
Abs ain om solid ood 6 h be o e su ge y and clea liquids 2 h be o e su ge y
2 h be o e su ge y P eemp i e medica ion PO
Ace aminophen 1000 mg
T anexamic acid 1000 mg
15 min be o e
su ge y
Dexame hasone 4 mg IV
P opo ol 5 mg/kg/h con inuous IV in usion pump
Al en anil 0.5 mg IV be o e he in e cos al block and when pa ien esponds o pain s imuli
In e cos al block
20 ml Ropi acaine 0.375%, 4 mg dexame hasone, and epineph ine (1:100.000) pe side
5 min be o e
incision
Local anes hesia
20–100 ml Lidocaine 0.1% wi h epineph ine (1:500.000) pe side
In aope a i e S ess- educing s a egies (communica ion skills, backg ound music, p o essional and an icipa ing eam)
No monopola elec ocau e y
Wa ming blanke s and wa med umescen solu ions
48 h a e su ge y P eemp i e analgesia PO
Ace aminophen 500 mg and
Me amizole 500 mg al e na ely e e y 3 h
P o e na a medica ion PO
Tilidine/naloxone (50/4 mg) slow- elease able s
Dimenhyd ina e 150 mg
Pos ope a i e Ambula ion wi hin he i s hou
Discha ge upon ole ance o ood, oiding, ambula ion wi hou assis ance, absence o in ole able pain, and absence o
nausea
Discha ge le e including pos ope a i e ins uc ions, ollow-up appoin men s
Cellula elephone access o su geon
Rou ine ollow-up call by he su geon 12 h a e he su ge y
Knee-high comp ession s ockings o 10 days
123
Aes h Plas Su g
(36–25) yea s o age we e included in his s udy. Eigh y-
one pe cen o pa icipan s we e women, and he median
(IQR) BMI was 24 (26–22) kg/m
2
. Como bidi ies, medi-
ca ion, and ASA sco e a e p esen ed in Table 2.
Nea ly hal o all su ge ies pe o med we e b eas aug-
men a ions. B eas educ ions comp ised 35% and
gynecomas ia abou 17% o all su gical in e en ions.
Mas opexy was pe o med in 23% o pa ien s. Six y-nine
pe cen o he su ge ies in ol ed addi ional p ocedu es
such as liposuc ion.
The median ope a ing ime was 02:12 (IQR:
02:49–01:36) hou s. Gynecomas ia co ec ions we e he
sho es p ocedu es (median (IQR) 1:42 (1:52–1:09) hou s)
and b eas educ ions he longes (median (IQR) 2:37
(2:58–1:52) hou s). The median (IQR) du a ion o b eas
augmen a ion (including implan and a g a only, as well
as hyb id b eas augmen a ion) was 2:14 (2:49–1:35) hou s.
The a e age doses o adminis e ed al en anil and
p opo ol we e, espec i ely, 0.31 lg/kg/min (minimum
0.02, maximum 0.83 lg/kg/min) and 4.43 mg/kg/h (mini-
mum 2.27, maximum 6.21 mg/kg/h).
Sa is ac ion wi h Ou come
Ou esul s show a s a is ically signi ican inc ease in sa -
is ac ion wi h b eas appea ance, as well as psychological
and sexual well-being pos ope a i ely (Table 3). The e was
an inc ease o 32 poin s (pB0.001) in pa ien sa is ac ion
wi h b eas s, 18 poin s (pB0.001) in psychosocial well-
being, and 10 poin s (pB0.001) in sexual well-being. Six y-
wo pe cen o he esponden s epo ed 100% sa is ac ion
wi h he ou come.
App ehension Be o e and A e Anes hesia
The g ea es p eope a i e conce ns o pa ien s we e
epo ed using a 1 (no a all) o 5 ( e y s ong) a ing scale,
and we obse ed a s a is ically signi ican educ ion pos -
ope a i ely (pB0.001) in all ca ego ies (Fig. 1). In his
se ies o ou pa ien aes he ic b eas su ge y unde seda ion,
in e cos al block, and umescen anes hesia, mos pa ien s
epo ed li le o no conce n abou anes hesia (median
(IQR) 2 (2–1)) and abou eeling pain, nausea, o dyspnea
(median (IQR) 2 (3–1)) be o e he p ocedu e. This app e-
hension aded pos ope a i ely, and pa ien s e ealed ha -
ing no ea (median (IQR) was 1 (2–1) in all ca ego ies).
Mode a e, s ong, o e y s ong conce ns ega ding he
anes hesia in he o m o conscious seda ion we e exp es-
sed by 17% o pa ien s be o e he su ge y and only by 4%
o he pa ien s a e he su ge y (Fig. 1).
The e was no s a is ically signi ican co ela ion
be ween p eope a i e anxie y and he dose o al en anil o
be ween anxie y and he dose o p opo ol equi ed du ing
su ge y (
s
=-0.286) (Table 4). A powe analysis o
es ima ion o he sample size which compa ed he p eop-
e a i e and pos ope a i e conce ns showed ha he e ec
size o ou s udy was ex emely la ge (powe 1.000, alpha
0.050).
An icipa ed and Ac ual Reco e y
Pa ien s e u ned o mos daily ac i i ies wi hin 5 days a e
su ge y. Se en y-one pe cen o pa ien s we e able o
pe o m mos daily ac i i ies soone han an icipa ed
(p 0.001). Pa ien s we e able o wash hemsel es, climb
s ai s, and go o walks s a is ically signi ican ly ea lie
han an icipa ed (Table 5). The i s ac i i ies o be pe -
o med we e walking a ound he house and climbing s ai s.
Pa ien s we e able o d ess o und ess and go o a walk
ou side on he ollowing day, and o cook a meal and
Table 2 Demog aphic da a (age, BMI, como bidi ies, medica ion,
ASA sco e)
Age median (IQR) 30 (36–25)
BMI median (IQR) 24 (26–22) kg/m2
Sex 39 (81%) women
ASA I 34 (71%)
ASA II 14 (29%)
Como bidi ies* No como bidi ies: 40
(83%)
3 (6%) hy oid
disease
2 (4%) a e ial
hype ension
2 (4%) as hma
4 (8%) o he
Medica ion* No medica ions: 34
(71%)
8 (17%) ho monal
con acep ion
3 (6%) le o hy oxine
2 (4%)
an ihype ensi e
d ugs
5 (10%) o he
P o ession (acco ding o he In e na ional
S anda d Classi ica ion O Occupa ions,
ISCO-08):
5 (10%) skill le el 1
17 (35%) skill le el 2
9 (19%) skill le el 3
7 (15%) skill le el 4
7 (15%) no
applicable
3 (6%) no
men ioned
*The o al numbe does no sum o 48 (100%)
123
Aes h Plas Su g
Table 3 BREAST-Q sco es and g ouping o di e en su gical echniques a e shown (Rasch ans o med sco e ange, 0–100). Highe sco es indica e highe sa is ac ion
Su ge y ype To al Ques ionnai e Sa is ac ion wi h b eas s Psychosocial well-being Sexual well-being Sa is ac ion
wi h ou come
P eope a i e Pos ope a i e p alue** P eope a i e Pos ope a i e p alue** P eope a i e Pos ope a i e p alue**
B eas
augmen a ion
7 BREAST-Q 22 (33 –11) * 96 (100–82)* p= 0.001 39 (58 –33) 89 (100–71)* p= 0.003 40 (55 –20) 85 (100–68)* p= 0.001 100 (100–
89)*
Augmen a ion
mas opexy
1
Hyb id b eas
augmen a ion
8
Implan
exchange and
mas opexy
1
Fa ans e 6
B eas educ ion
and mas opexy
1 BREAST-Q
Reduc ion/
Mas opexy
44 (65–17) 94 (100 –
88)*
p= 0.002 39 (63–28) 94 (100–75)* p=
0.001
28 (39–15) 80 (100–69) p=
0.001
100 (100–81)
Mas opexy and
a ans e
4
Mas opexy 11
Implan emo al
and mas opexy
1
Gynecomas ia 8 40 (95–15) 80 (89–13) p= 0.046 80 (89–13)
To al/Mean 48 22 (50–16)* 94 (100–81)* p= 0.001 39 (59–31) 92 (100–75)* p= 0.001 33 (46–20) 83 (100–66) * p=
0.001
100
(100–84)*
All sco es a e median (IQR)
*Skewed a iable
**Wilcoxon signed- ank es
123
Aes h Plas Su g

showe on he second pos ope a i e day. Ac i i ies ha
equi ed a longe eco e y ime o be accomplished we e
doing housewo k and shopping (on he ou h pos ope a i e
day) as well as d i ing a ca (on he i h day) (Table 5).
The speed o eco e y did no co ela e wi h he ope -
a ing ime (
s
= 0.068, p=0.650) (Table 6). Nei he he
al en anil no he p opo ol dosages co ela ed signi ican ly
wi h he speed o eco e y (Table 6). Reco e y ime was
simila ac oss ca ego ies, pa ien s needed a median (IQR)
o 2 (2–1), 2(3–1), and 2 (2–1) days a e b eas augmen-
a ion, educ ion, and gynecomas ia su ge ies, espec i ely,
o e u n o no mal daily ac i i ies. Eigh y-eigh pe cen o
pa ien s equi ed less ime o exac ly he same ime o
eco e as an icipa ed p eope a i ely. Howe e , pa ien s
wi h a slowe eco e y han an icipa ed we e no less sa -
is ied wi h he aes he ic esul han pa ien s whose eco e y
was as as o as e han an icipa ed ( ank-sum es :
p=0.180). Powe analysis showed a powe o 0.983 o
de ec a di e ence o alpha 0.05 be ween p eope a i e
conce ns and pos ope a i e eco e y.
Discussion
We belie e his is he i s s udy o assess pa ien s’ anxie y,
expec a ions, sa is ac ion, and ac ual eco e y ime a e
ERAS pa hways o ou pa ien aes he ic b eas su ge y.
Pa ien s e u ned o mos daily ac i i ies wi hin 5 days
(Table 5). A e ospec i e s udy o da a collec ed be ween
1982 and 1990 sugges ed ha educ ion in su gical auma
enabled pa ien s o li objec s up o 20 pounds, d i e a ca ,
e u n o wo k, and lie p one on hei b eas s 24 h a e
submuscula b eas augmen a ion and gene al endo acheal
anes hesia [19]. In a p ospec i e s udy o pa ien s a e
submuscula b eas augmen a ions, pa ien s esumed d i -
ing a e 5.4 ±4.1 (min: 1, max: 21) days a e su ge y.
Howe e , no de ails we e gi en on he numbe and ype o
Fig. 1 Pa ien - epo ed conce ns abou p eope a i e (ligh blue) as
well as pos ope a i e (da k blue) anxie y and ea o anes hesia
(Be o e: ‘‘When I hink abou he upcoming anes hesia, I am
conce ned ha ...’’; A e : ‘‘I I needed his o m o anes hesia in he
u u e, I would be conce ned ha ...’’). Scale 1: no a all; 2: a li le; 3:
mode a ely; 4: s ongly; and 5: e y s ongly
Table 4 Spea man’s co ela ion o p eope a i e conce ns and su gical and anes he ic pa ame e s
Sa is ac ion
wi h b eas s
Psychosocial
well-being
Sexual
well-
being
BMI P ocedu e
du a ion
(min)
To al al en anil dose
pe pa ien (lg/kg/min)
To al p opo ol dose
pe pa ien (mg/kg/h)
P eope a i e anxie y
and ea o
anes hesia:
s= 0.119 s= -0.179 s=
-0.123
s=
0.152
s= -0.082 s= -0.090 s= -0.286
p= 0.435 p=0.283 p=0.462 p=0.303 p=0.578 p=0.609 p=0.095
123
Aes h Plas Su g
Table 5 P eope a i e pa ien s’ expec a ions ega ding eco e y and e u n o no mal daily ac i i ies (‘‘Please es ima e you physical i ness in he i s 7 days a e su ge y.’’) and pos ope a i e
assessmen o eco e y and e u n o no mal daily ac i i ies in he i s 7 days a e su ge y (‘‘When did you physically eel able o pe o m he ollowing ac i i ies.’’)
Days a e su ge y on which he pa ien an icipa ed (be o e su ge y) and ac ually was able o pe o m he ollowing ac i i ies (a e su ge y):
Scale: 0: Day o Su ge y; 1: 1s day; 2: 2nd day; 3: 3 d day; 4: 4 h day; 5: 5 h day; 6: 6 h day; 7: 7 h day; 8: A e 1 week
To wash you sel (wi h showe
plas e )
To d ess o und ess To walk in he house/apa men To climb s ai s (1 loo ) To go o a walk ou side (10
minu es)
Su ge y ype P eope a i e Pos
ope a i e
p alue** P eope a i e Pos ope a i e p alue** P eope a i e Pos ope a i e p
alue**
P eope a i e Pos ope a i e p alue** P e
ope a i e
Pos ope a i e P
alue**
B eas
Augmen a ion
2 (2 -1) 2 (3 -1) p=0.239 1 (2–0) 2 (2–0) * p=0.048 0 (1–0)* 1 (2–0)* p=0.615 1 (2–0) 1 (1–0)* p=0.302 2 (3–1) 2 (2–1) p=0.161
B eas educ ion/
Mas opexy
1 (3–1)* 2 (4–1) p=0.123 1 (2–0)* 1 (2–0)* p=0.230 0 (1–0)* 0 (1–0)* p=0.107 1 (2–0)* 0 (1–0)* p=0.048 1 (3–1)* 1 (2–0) p=0.088
Gynecomas ia 1 (3–1) 3 (3–1) p=0.063 1 (2–0) 1 (2–0)* p=0.518 1 (2–0)* 0 (1–0) p=0.705 1 (1–0) 0 (1–0) p=1.000 1 (3–0) 1 (1–0) p=1.000
To al/Median
(IQR)
2 (3 - 1)* 2 (3 - 1) p=0.014 1 (2 –0)* 1 (2 –0)* p=0.323 0 (1–0)* 0 (1 - 0) * p=0.438 1 (2 - 0) * 0 (1 - 0) * p=0.042 2 (3 - 1)
*
1(2-1) p=0.031
Days a e su ge y on which he pa ien an icipa ed (be o e su ge y) and ac ually was able o pe o m he ollowing ac i i ies (a e su ge y):
Scale: 0: Day o Su ge y; 1: 1s day; 2: 2nd day; 3: 3 d day; 4: 4 h day; 5: 5 h day; 6: 6 h day; 7: 7 h day; 8: A e 1 week
To cook (a small meal o you sel ) To do housewo k (washing clo hes, acuuming he loo ) To go shopping (g oce ies) To d i e a ca (up o 50 km)
Su ge y ype P eope a i e Pos ope a i e P alue** P eope a i e Pos ope a i e P alue** P eope a i e Pos ope a i e P alue** P eope a i e Pos ope a i e P alue**
B eas Augmen a ion 2 (4 -1) 2 (3 -1)* p=0.976 5 (7–3) 5 (5 - 4) p=0.961 5 (7 - 3) 4 (5 - 4) p=0.728 6 (8–3) 5 (8–2) p=1.000
B eas educ ion/Mas opexy 2 (5–1) * 2 (4–1) * p=0.112 4 (8–2) 4 (5–2) p=0.038 5 (8–3) 5 (6–2) p=0.181 7 (8–2) 6 (8–3) p=0.964
Gynecomas ia 1 (2–1)* 1 (2–1)* p=0.102 4 (7–2) 4 (5–3) p=0.671 4 (6–2) 3 (4–3)* p=0.317 2 (5–2)* 4 (8–3) p=0.139
To al/Median (IQR) 2 (4–1) * 2 (3–1)e p=0.659 4 (7–3) 4 (5–3) p=0.110 5 (7–3) 4 (5–3)* p=0.236 6 (8–2) 5 (8–3) p=0.472
All sco es a e median (IQR)
*Skewed a iable
**Wilcoxon signed- ank es
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Aes h Plas Su g
combined p ocedu es and he ype o anes hesia [6]. The
li e a u e pe aining o exe cise a e b eas su ge y shows
no subs an ial e idence o ad e se ou comes due o ea ly
pos ope a i e exe cise compa ed wi h delayed exe cise
[20]. Recen e idence sugges s ha exe cise, including
bench p ess, 1 week a e b eas augmen a ion does no
inc ease complica ion a es [21]. Ne e heless, addi ional
s udies may be equi ed o de e mine he op imum isk–
bene i a io be ween o e ly agg essi e and o e ly cau ious
eco e y.
Ou indings co obo a e ha wi h op imal pe iope a i e
p o ocols complex su gical ope a ions can be pe o med in
an ou pa ien se ing [22]. S udies sugges ing ha he
ope a ion ime p edic s he i ness o discha ge do no
conside he impac o gene al anes hesia on eco e y [23],
al hough a co ela ion be ween he ype o anes hesia and
he quali y o eco e y has been demons a ed [24,25].
Unde he s anda dized anes hesia p o ocol desc ibed
he ein, he ange o ope a ing imes (min: 46 min; max:
293 min) did no co ela e wi h he eco e y ime wi hin
he i s pos ope a i e week (Table 6). This may be
explained by he o e all low doses o p opo ol and al en-
anil and hei ela i ely sho elimina ion hal -li e (558 ±
218 and 275 ±94 minu es, espec i ely) [26]. Pa ien s
equi ed a median (IQR) p opo ol dose o 4.97
(6.21–2.27) mg/kg/h, in con as o he concen a ions used
in o al i. . anes hesia o 9 mg/kg/h as ini ial dose and
6 mg/kg/h as he main enance dose [27]. As o al en anil,
he median (IQR) in usion a e was 0.33 (0.83–0.02) lg/
kg/min, as opposed o he dose used in o al i. . anes hesia
o 100 o 240 lg/kg/min [27]. The highe doses o p opo ol
and al en anil ypically adminis e ed in gene al anes hesia
di icul eco e y, especially in he i s 48 h, and he e o e
a e mo e likely o equi e inpa ien hospi aliza ion pos -
ope a i ely. The au ho s ha e p e iously shown ha
pa ien s a e aes he ic b eas su ge y acco ding o he
ERAS p o ocol desc ibed he ein a e eco e ing soone han
expec ed a e gene al su ge y (d inking, ea ing, and
oiding wi hin a median (IQR) o 0:45 (1:19–0:25) h,
discha ge wi hin a median o 2:40 (3:43–1:58) h [13].
The isk o h omboses in cosme ic su ge y, including
b eas and ace su ge ies, abdominoplas ies, and liposuc-
ions, is es ima ed a 0.9% and peeks a app oxima ely
1 week a e su ge y [28]. Ea ly mobiliza ion and eco e y
a e decisi e o p e en h omboembolisms. Mos pa ien s
in his s udy walked in hei house o apa men and
climbed s ai s on he day o he su ge y, which would no
be possible in a hospi al oom, especially a e gene al
su ge y. A signi ican ly lowe incidence o h omboem-
bolism has been obse ed in a la ge published se ies o
pa ien s unde going elec i e plas ic su ge y unde o al
in a enous anes hesia [29]. Discussion on he associa ion
o h omboembolic e en s wi h ope a i e ime mus
acknowledge he po en ially con ounding e ec o gene al
anes hesia. Pain, nausea, and d owsiness a e he mos e-
quen causes o delaying discha ge [30]. E idence has
been p esen ed ha opioid-spa ing anes hesia imp o es
eco e y wi hou comp omising pa ien sa e y and pain
con ol [13,25].
Se en y-one pe cen o pa ien s equi ed as much ime
o eco e as an icipa ed p eope a i ely o less. E idence
has been p esen ed ha p eope a i e in o ma ion desc ib-
ing he eco e y p ocess educes he leng h o hospi al s ay
[31]. Well-in o med pa ien s p esen as e ime o ac i i y
and eco e y [38], a e mo e sa is ied wi h hei o e all
ou come [41], and consume ewe opioids [32]. Commu-
nica ion gaps and un ealis ic expec a ions inc ease he isk
o pos ope a i e complica ions [33]. Pa ien s p o ided wi h
adequa e in o ma ion and de ails abou wha o expec
ega ding he p ocess o ca e and eco e y a e mo e sa -
is ied wi h hei o e all ou come [34]. We, he e o e,
assume ha p o iding he in o ma ion desc ibed he ein
du ing p eope a i e counseling can u he enhance
eco e y, inc ease sa is ac ion, and educe opioid con-
sump ion. Because o he amoun and impo ance o p e-
ope a i e in o ma ion, we ecommend wo appoin men s
o comp ehensi e counseling and he use p in ed and
digi al o ma s.
Since s ess and anxie y in luence pain pe cep ion,
immune unc ion, and wound healing, he ERAS p o ocol
included nume ous measu es o educe anxie y. S uc u ed
ollow-up calls, 12 o 24 h a e ambula o y su ge y
po en ially educes pa ien s’ sel - epo ed pain and anxie y,
and imp o es sa e y and ou comes by inc easing compli-
ance while educing he a eling imes, in as uc u e
needs, and con agion isk du ing he COVID-19 pandemic
Table 6 Co ela ion o eco e y and su gical and anes he ic pa ame e s
Sa is ac ion
wi h b eas s
Psychosocial
well-being
Sexual
well-
being
Sa is ac ion
wi h
ou come
BMI P ocedu e
du a ion
(min)
To al al en anil dose
pe pa ien (lg/kg/
min)
To al p opo ol dose
pe pa ien (mg/kg/
h)
Reco e y
a e
su ge y:
s= -0.057 s= -0.023 s=
-0.017
s= 0.025 s=
0.015
s= 0.068 s= 0.158 s= -0.121
p=0.708 p=0.890 p=0.912 p=0.935 p=0.920 p=0.650 p=0.372 p=0.496
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Aes h Plas Su g
[35–38]. Ha ing cellula elephone access has p omising
bene i s o he pa ien –physician ela ionship [39] and is
ecommended o accoun o he isks o hema oma and he
a e isk o lidocaine in oxica ion ha may occu in he i s
24 h a e su ge y [17]. In o ma ion and beha io al
ins uc ions ha e he po en ial o minimize s ess and
anxie y and imp o e pos ope a i e ou comes [40]. Only six
pa ien s had a slowe eco e y han hey had an icipa ed.
Rega ding he pa ien s ha eco e ed as as o as e han
hey expec ed, he speed o eco e y did no a ec o e all
sa is ac ion (Table 6).
P eexis ing men al heal h condi ions, including dep es-
sion, anxie y diso de s, and subs ance abuse, ha e been
no ed o be impo an p eope a i e isk ac o s o ad e se
ou comes, esul ing in inc eased likelihood o hospi al-
based acu e ca e pos ope a i ely [41]. Besides ASA III
classi ica ion, which includes BMI C40, he s eng h o
co ela ion and op imal cu o alues o pa ien selec ion
pa ame e s o ou pa ien ca e a e unknown [42]. Since
ambula o y su ge y has many ad an ages, u he s udies
a e needed o app op ia e pa ien selec ion (Table 7).
This s udy mus acknowledge some limi a ions. This
s udy did no ha e ma ched con ols o pa ien s unde going
a s anda d pe iope a i e model o ca e o s anda d gene al
anes hesia. Howe e , he empi ical compa ison o he
ERAS pa hway wi h he au ho ’s p io expe ience shows
ha eco e y is much sho e and less pain ul, especially in
he i s 24 h wi h he p o ocol desc ibed he ein. Besides,
because ERAS has been shown o be mo e e ec i e when
compa ed o s anda d p o ocol, doing so was deemed
une hical. A esponse bias ega ding eco e y expec a ions
can be uled ou since only ques ions ega ding he ea lies
ime o showe and d i e a e su ge y we e occasionally
asked. We only p esen da a om one ins i u ion; hus, he
indings migh no be gene alizable o o he ins i u ions.
Addi ionally, al e na i e anes he ic me hods migh no be
compa ible wi h he indings o his s udy. Because o he
he e ogenei y o p o essional ac i i ies, enhanced pos op-
e a i e eco e y is mo e eliably de e mined by he e u n
o compa able ac i i ies o daily li ing. To sa is y he call
o he use o ep oducible and alida ed ques ionnai es,
s udies may be inclined o use es ablished and alida ed
ins umen s, comp omising sensi i i y and consis ency
[12]. We ha e used he BREAST-Q ques ionnai e o
e alua e sa is ac ion a e a g a ing o he b eas ,
acknowledging issues ega ding he consis ency o se e al
i ems (‘‘The posi ion o you implan s on you ches ( oo
high o oo low)’’; ‘‘How e enly you implan s a e posi-
ioned in ela ion o each o he ?’’). Fac o s associa ed wi h
hospi al expe ience ( oom com o , cleanliness, noise le el,
ood se ice, ba h oom com o , e c.) a e con ounding
ac o s a ec ing pa ien sa is ac ion wi h he ou come [43].
Since his s udy only in ol ed ambula o y su ge y, he
impac o hospi al expe ience on pa ien sa is ac ion can be
uled ou . Addi ional liposuc ion pe o med in 69% o
pa ien s may accoun o an o e es ima ion o esidual
pain, despi e a high com o due o in e cos al blocks.
Howe e , pa ien s wi h liposuc ion did no ha e signi i-
can ly mo e pain han pa ien s wi hou liposuc ion ( ank-
sum es ; p= 0.788). Fo op imal sensi i i y and consis-
ency, a ques ionnai e add essing impo an issues on
eco e y a e aes he ic b eas su ge y has been de eloped
o his esea ch. The ques ionnai e is p o ided in he
appendix o c i ical app aisal o alidi y o ep oducibil-
i y. Recall bias can be excluded.
Conclusion Fas Reco e y Su ge y
Pa ien s and su geons o en expec aes he ic b eas su ge y
o be pe o med unde gene al anes hesia and ha e mod-
e a e app ehension abou seda ion, in e cos al block, and
Table 7 Ad an ages o ou pa ien ca e
Ou pa ien ca e e sus o e nigh hospi al s ays
Ambula ion Ou pa ien s walk a ound hei house and climb s ai s on he day o hei su ge y and can go o a 10min walk
ou side on he i s pos ope a i e day (Table 5)
Th ombosis Ou pa ien s ha e a smalle isk o h omboembolism [29]
Sleep Ou pa ien s ha e a be e sleep [44]
Com o Ou pa ien s bene i om a amilia en i onmen and mo e p i acy [44]
Opioid medica ion Ou pa ien s a e less likely o become pe sis en opioid use s [45]
Hospi al-acqui ed bac e ial
in ec ions
Ou pa ien s ha e a smalle isk o d ug- esis an in ec ions [46]
Hospi al-acqui ed COVID-
19
Ou pa ien s ha e a lowe isk o nosocomial COVID-19 ansmission [47]
Cos s Ou pa ien ea men s a e associa ed wi h lowe cos s [48,49]
Risks/Su eillance Rou ine moni o ing o i al signs du ing o e nigh hospi al s ays is no e ec i e and o en inaccu a e [50]
A s uc u ed elephone/ elemedicine ollow-up call by su geon 12 h pos ope a i ely is ad ised [13]
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