Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

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 123 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=0.496 123 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] 123 Aes h Plas Su g