Download PDF
J Reconstr Microsurg
DOI: 10.1055/a-2616-4598
Original Article

Impact of Judicious Fluid Administration in the Setting of Abdominally Based Free Flaps

Lyndsay A. Kandi
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Illinois
,
Nicole Van Spronsen
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
,
W. Nicholas Jungbauer  Jr
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
,
Jaime Sexton
3   Department of General Surgery, University of Connecticut, Farmington, Connecticut
,
Nellie Movtchan
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
,
Yu-Hui Chang
4   Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
,
Edward Reece
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
,
Alanna M. Rebecca
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
,
William J. Casey III
2   Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic in Arizona, Phoenix, Arizona
› Author Affiliations
Funding None.
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background

Abdominally based free flaps are commonly utilized in the context of breast reconstruction. Historically, postoperative care of these patients involved liberal amounts of intravenous fluid administration; however, overadministration of fluids puts patients at risk of developing flap edema via fluid shifts, electrolyte imbalances, wound dehiscence, and other sequelae. The purpose of this study is to assess fluid administration trends in this cohort at the authors' institution and assess its impact on patient outcomes.

Methods

A retrospective review was performed on patients who underwent free-flap breast reconstruction. Patient demographics and hospitalization data were collected, and type of abdominal flap and reconstruction timing was noted. Perioperative fluid administration volumes were tracked, and primary outcomes included complication rate and type (e.g., acute blood loss anemia [ABLA], partial/total flap loss, etc.). Multivariable logistic regression was performed to assess the impact of fluid volume on patient outcomes.

Results

A total of 115 patients (mean age of 51.3 ± 10.5 years) underwent 188 abdominally based free flaps. Deep inferior epigastric artery perforator flaps were performed most often (n = 91), followed by muscle-sparing transverse rectus abdominis flaps (n = 88). Multivariable logistic regression demonstrated that high perioperative fluid administration (≥9,000 mL) was associated with increased odds of medical complications (odds ratio [OR] = 21.7; confidence interval [CI]: 5.54–84.5; p < 0.001). Patients with high fluid administration volumes experienced an increased (but nonstatistically significant) flap complication rate (OR = 2.96; CI: 0.89–9.88; p = 0.08) and developed ABLA at a higher rate (OR = 15.86; CI: 5.30–46.4; p < 0.001).

Conclusion

High-volume resuscitation (≥9,000 mL) was associated with increased odds of ABLA as well as a greater likelihood of medical and flap complications in patients undergoing abdominally based free flaps for breast reconstruction. These data should be used to guide the development of protocols within institutions, which perform free flaps for breast reconstruction.

Keywords

fluid administration - DIEP - free flap - ERAS


Publication History

Received: 19 December 2024

Accepted: 12 May 2025

Accepted Manuscript online:
20 May 2025

Article published online:
17 June 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Schnur JB. et al. Breast reconstruction patients' emotional well-being: correlates and pre-surgery patient experience. Plast Reconstr Surg 2007; 120 (05) 1237-1242
    PubMedSearch in Google Scholar
  • 2 Dean NR, Watson BM, Crittenden TA. Breast reconstruction: impact on quality of life and patient satisfaction. Breast 2018; 39: 58-64
    PubMedSearch in Google Scholar
  • 3 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
    CrossrefPubMedSearch in Google Scholar
  • 4 Nahabedian MY. The evolution of abdominally based microsurgical breast reconstruction. Plast Reconstr Surg 2012; 129 (01) 3-10
    PubMedSearch in Google Scholar
  • 5 Horch RE, Bannasch H, Stark GB, Arkudas A. Microsurgical breast reconstruction: the latest developments and current trends. Ann Plast Surg 2005; 54 (05) 477-484
    PubMedSearch in Google Scholar
  • 6 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183 (06) 630-641
    CrossrefPubMedSearch in Google Scholar
  • 7 Mast BA, De Bruin M, Kramer A, van Leeuwen TG. ERAS in plastic surgery: ERAS pathway for breast reconstruction. Plast Reconstr Surg 2020; 146 (02) 489-496
    PubMedSearch in Google Scholar
  • 8 Bastos EM, Araújo GS, Amorim PM. Effects of fluid therapy on surgical outcomes. World J Surg 2019; 43 (02) 346-357
    PubMedSearch in Google Scholar
  • 9 Payne SR. et al. Goal-directed fluid therapy in reconstructive surgery. Plast Reconstr Surg 2017; 140 (06) 1091-1100
    PubMedSearch in Google Scholar
  • 10 Boyd KU, Nardelli P, Weaver J, O'Grady LF. Autologous breast reconstruction: current controversies and techniques. Can J Plast Surg 2014; 22 (02) 97-101
    PubMedSearch in Google Scholar
  • 11 Afonso A, Oskar S, Tan KS. et al. Is enhanced recovery the new standard of care in microsurgical breast reconstruction?. Plast Reconstr Surg 2017; 139 (05) 1053-1061
    CrossrefPubMedSearch in Google Scholar
  • 12 Polanco TO, Shamsunder MG, Hicks MEV. et al. Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise. J Plast Reconstr Aesthet Surg 2021; 74 (09) 2227-2236
    CrossrefPubMedSearch in Google Scholar
  • 13 Soteropulos CE, Tang SYQ, Poore SO. Enhanced recovery after surgery in breast reconstruction: a systematic review. J Reconstr Microsurg 2019; 35 (09) 695-704
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Speck NE, Michalak M, Dreier K, Babst D, Lardi AM, Farhadi J. Effect of the Red Bull energy drink on perfusion-related variables in women undergoing microsurgical breast reconstruction: protocol and analysis plan for a prospective, multicenter randomized controlled trial. JMIR Res Protoc 2023; 12: e38487
    PubMedSearch in Google Scholar
  • 15 Temple-Oberle C, Shea-Budgell MA, Tan M. et al; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery after Surgery (ERAS) Society recommendations. Plast Reconstr Surg 2017; 139 (05) 1056e-1071e
    CrossrefPubMedSearch in Google Scholar
  • 16 Ruccia F, Savage JA, Sorooshian P, Lees M, Fesatidou V, Zoccali G. Hyponatremia after autologous breast reconstruction: a cohort study comparing two fluid management protocols. J Reconstr Microsurg 2023; 39 (01) 35-42
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Justiz Vaillant AA, Zubair M, Sticco KL. Transfusion Transmitted Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024
    Search in Google Scholar
  • 18 Stephens KL, DeVito RG, Hollenbeck ST, Campbell CA, Stranix JT. Effect of enhanced recovery after surgery in morbidly obese patients undergoing free flap breast reconstruction. J Reconstr Microsurg 2025;
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 Goh CSL, Ng MJM, Song DH, Ooi ASH. Perioperative vasopressor use in free flap surgery: a systematic review and meta-analysis. J Reconstr Microsurg 2019; 35 (07) 529-540
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Carr J, Orvin D. Large-volume intravenous fluid use before and after implementation of a fluid conservation strategy. Am J Health Syst Pharm 2024; zxae330
    CrossrefPubMedSearch in Google Scholar