COVID-19 microsurgical breast reconstruction national practise survey: A survey of BAPRAS members and proposal of COVID-19 specific perioperative and ERAS pathways

Dear Sir

Breast reconstruction is one of the largest subspecialties within plastic surgery. The ‘Clinical Guide to Surgical Prioritisation During the Coronavirus Pandemic’ published by the Federation of Surgical specialty Associations during the COVID-19 pandemic defines breast reconstruction as a non-urgent priority 4 (surgery that can be delayed > 3 months) procedure. As such, breast reconstructive services have largely ceased. Recovery strategies have now been implemented to mitigate COVID-19 risk with both British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the Association of Breast Surgery producing guidance on recommencing breast reconstruction services.1, 2, 3 These guidelines advocate breast reconstruction, whilst highlighting existing issues to be addressed, challenges and potential opportunities. However practical advice on adapting referral pathways or enhanced recovery after surgery (ERAS) pathways during COVID-19 have not been addressed. Whilst existing ERAS pathways have been shown to reduce complication rates and shorten hospital stay for patients, they clearly need modification during the recovery from the pandemic but also in light of a potential second wave.^{4 , 5}

We sought to obtain national consensus regarding microsurgical breast reconstruction, recovery strategies and future adaptations of services with the aim of generating a robust perioperative pathway for immediate microsurgical breast reconstruction. An electronic survey was designed using Google Forms and distributed to all members of the BAPRAS Breast Special Interest Group (SIG). Response rate in relation to absolute number of UK plastic surgery units was assessed.

21 responses were received representing a response rate of 33% (n = 20). Results indicate that all units ceased microsurgical breast reconstruction due to the pandemic with the majority (24%, n = 5) stopping on March 18th 2020. Only 14% (n = 3) had resumed operating at the time of responding. 57% (n = 12) of units are currently offering immediate microsurgical breast reconstruction whereas only 33% (n = 7) are offering delayed microsurgical reconstruction. The mean number of autologous microsurgical breast reconstructions performed annually by respondents was 102 (10–355). Extrapolating this data and assuming that all units in the UK perform microsurgical breast reconstruction, there were 1743 missed autologous microsurgical breast reconstructions nationally, at the time of survey completion. 76% (n = 16) of units are holding face to face breast clinics but 81% (n = 17) signalled that these have been reduced, with 48% (n = 10) and 86% (n = 18) of units conducting virtual clinics for new and follow-up patients respectively. 71% (n = 15) of units have a full-time breast reconstruction clinical nurse specialist (CNS), but despite 91% (n = 19) regarding a breast reconstruction CNS as an essential component to their service, 61% (n = 11) of units had their breast reconstruction CNS re-deployed during COVID-19. 29% (n = 6) of units have had to relocate their service due to resource pressures. 52% (n = 11) had a ‘cold’ COVID-19 operating facility where this was undertaken. 38% (n = 8) had capacity in the private sector to offer microsurgical breast reconstruction for NHS patients. 43% (n = 9) were operating on priority level 3 patients (surgery that can be delayed for up to 3 months), whilst 48% (n = 10) were operating on priority level 3 and 4 patients and 10% (n = 2) were not operating on either priority. All units had adapted their peri‑operative pathway in view of COVID-19. All respondents recommended self-isolation pre-operatively, with 95% (n = 20) recommending a period of 14 days. The mean time to undertake pre-operative testing for COVID-19, or intention to undertake for those units not currently operating, was 3 (1–14) days. 81% (n = 17) were using a viral based test, 14% (n = 3) an antibody test and 5% (n = 1) did not know which test was employed pre-operatively. 95% (n = 20) specifically addressed COVID-19 associated risks in their consent process. 81% (n = 17) routinely use CT angiogram prior to carrying out microsurgical breast reconstruction but only 11% (n = 2) currently, or plan to, undertake a pre-operative CT thorax at the same time as the CT angiogram for purposes of COVID-19 detection in asymptomatic, isolated and tested patient. Participants were asked to record key changes in their referral and peri‑operative pathways as free text. Results were thematically analysed and included virtual consultations, pre-operative SARS-CoV-2 testing, perioperative self-isolation and a modified ERAS pathway. The details of these individual components were distilled into a referral and perioperative pathway (Figure 1 ), and ERAS pathway (Figure 2 ) that we suggest for immediate microsurgical breast reconstruction.

Figure 1.

Referral and perioperative pathway for immediate microsurgical breast reconstruction.

*High risk as defined as: organ transplant, chemotherapy or immunotherapy, radical radiotherapy, targeted cancer treatment, leukaemia, lymphoma, myeloma, bone marrow or stem cell transplant within 6 months, immunosuppressant medication, severe lung disease i.e. COPD, severe asthma, cystic fibrosis, sickle cell disease, serious heart disease, pregnancy.

Figure 2.

ERAS pathway.

As breast reconstruction services are re-established, COVID-19 risk needs to be mitigated. National consensus should be taken to avoid inequalities in reconstructive services provided, and avoidance of a cohort of patients with functional, aesthetic and psychological sequalae as a result of missed microsurgical breast reconstruction. Results of this survey identify a way forward for microsurgical breast reconstruction during the COVID-19 era and offers a unique opportunity to re-evaluate the pre-COVID-19 service and offer an ERAS pathway. Adaptation and enhancing services from lessons learnt will be paramount to future practice in the event of a second wave or future pandemic.

Declaration of Competing Interest

None.