Methadone-Based Enhanced Recovery after Surgery Protocol in DIEP Flap Breast Reconstruction: A 4-Year Analysis

BACKGROUND: This study evaluates the effectiveness of the New York--Presbyterian/Weill Cornell methadone-based enhanced recovery after surgery (ERAS) protocol in reducing postoperative pain and narcotic consumption in patients undergoing deep inferior epigastric perforator flap breast reconstruction. METHODS: This study includes a retrospective non-ERAS cohort (2017 to 2020) and a prospective ERAS cohort (2021 to 2024) of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction at a single institution. Outcomes assessed included postoperative complications, length of hospital stay, vital signs, pain scores, opioid consumption, and outpatient opioid prescriptions after discharge. In addition, ERAS patients were surveyed on home opioid use for 14 days after discharge. RESULTS: A total of 216 patients from the ERAS group and 163 patients from the non-ERAS group were included. Patients in the ERAS group had a significantly shorter length of hospital stay (2.97 versus 3.37 days, P < 0.001) and lower average pain scores (2.37 versus 3.18, P < 0.001), peak pain scores (6.23 versus 7.47, P < 0.001), heart rates (85.5 versus 95.6, P < 0.001), and incidences of tachycardia (10.7% versus 28.2%, P < 0.001). Inpatient opioid consumption decreased by 51.4% (208.02 versus 101.02 morphine milligram equivalents [MMEs]), and outpatient opioid prescriptions were reduced by 22.2% (194.21 versus 151.83 MMEs, P < 0.001). Of the 216 surveys distributed to the patients in the ERAS group, 76 responses (35.19%) were received. Postdischarge opioid use averaged 70.78 MMEs. The median time to cessation was 3.0 days. CONCLUSIONS: Implementation of the New York--Presbyterian/Weill Cornell methadone-based ERAS protocol significantly improved recovery outcomes. These findings underscore the potential of methadone to enhance traditional ERAS protocols, supporting its broader adoption in plastic surgery.