Outpatient Mastectomy with Reconstruction at Ambulatory Surgery Centers

Authors: Lloyd K, Shern TP, Holt LR, Daly AE, Anderman KJ, Fell GG, Gadd MA, Verdial FC, Kwait RM, Tomczyk E, Ozmen T, Smith BL, Specht MC

Affiliation: Massachusetts General Hospital; Dana-Farber Cancer Institute, Boston, Massachusetts

Journal: Annals of Surgical Oncology, February 2026

PMID: 41708932

Key takeaways

• Same-day discharge was achieved in 88% of reconstructed mastectomy patients and in 100% of the ASC cohort.

• Older age, living more than 30 miles away, bilateral surgery, and afternoon PACU arrival predicted overnight admission.

• ASC cases had shorter PACU stays, fewer PACU issues, and similar 30-day complications versus HOPD cases.

• Estimated facility-fee savings were $1.79 million, or 61.2%, for 99 ASC cases compared with equivalent HOPD care.

• This is a strong systems and operations paper, but selection bias limits any claim that ASC location itself causes better outcomes.

Background

Same-day mastectomy pathways have expanded because they can reduce length of stay, opioid exposure, and hospital resource use without clearly worsening short-term outcomes. What remains less well defined is whether implant-based mastectomy with immediate reconstruction can be shifted safely from hospital outpatient departments to ambulatory surgery centers while preserving outcomes and lowering costs.

Objective

To identify predictors of overnight admission after same-day mastectomy with immediate implant or tissue expander reconstruction, and to evaluate the safety, feasibility, and cost profile of performing these cases at ambulatory surgery centers versus hospital outpatient departments.

Methods

• Design: Retrospective cohort study within a single health system.

• Setting: Two hospital outpatient departments and two ambulatory surgery centers.

• Study period: January 2023 to June 2024.

• Population: 559 consecutive women undergoing mastectomy with immediate implant-based or tissue expander reconstruction.

• Eligibility details: ASC patients had to meet center-specific criteria including BMI less than 45 kg/m2 and ASA class 3 or less; patients with difficult airway history, severe untreated sleep apnea, or prior major anesthetic problems were not eligible for ASC surgery.

• Case mix:

  • Median age 48 years.

  • 85.3% White.

  • 68.0% invasive cancer, 21.5% ductal carcinoma in situ, 10.5% prophylactic.

  • 67.6% bilateral procedures.

  • 58.7% direct-to-implant and 41.3% tissue expander reconstruction.

• Perioperative pathway: Standardized same-day mastectomy protocol with regional blocks, multimodal analgesia, antiemetics, and postoperative support.

• Comparisons:

  • Same-day discharge versus overnight stay.

  • Planned versus unplanned overnight stay.

  • ASC versus HOPD.

• Endpoints: PACU events, narcotic use, postoperative length of stay, 30-day complications, return to OR, readmission, and cost.

• Statistics: Multivariable binomial logistic regression for predictors of overnight admission; cost modeled using 2024 Medicare outpatient facility fees.

Results

• Discharge success:

  • 492 of 559 patients, or 88.0%, went home the same day.

  • 67 patients, or 12.0%, stayed overnight.

  • Of overnight stays, 35 were planned and 32 were unplanned.

• Independent predictors of any overnight admission:

  • Age greater than 65 years: OR 2.48.

  • Distance greater than 30 miles: OR 2.16.

  • Bilateral surgery: OR 2.44.

  • Afternoon PACU arrival: OR 2.01.

• Independent predictors of unplanned overnight admission:

  • Distance greater than 30 miles: OR 2.32.

  • Bilateral surgery: OR 3.02.

  • Afternoon PACU arrival: OR 2.70.

• PACU findings tied to unplanned admission:

  • Nausea and vomiting.

  • Hypotension.

  • Inadequate pain control.

• Safety:

  • Thirty-day complications were similar between same-day discharge and overnight-stay patients: 84 of 492 (18.3%) versus 14 of 67 (20.9%).

  • Hospital readmission within 30 days was also similar: 43 of 492 (8.7%) versus 9 of 67 (13.4%).

  • Return to OR within 30 days was similar as well: 41 of 492 (8.3%) versus 9 of 67 (13.4%).

  • Five hematomas requiring return to OR occurred within 24 hours; three had already been discharged and two were still in PACU.

• ASC versus HOPD:

  • Same-day discharge: 100.0% at ASCs versus 85.4% at HOPDs.

  • Median postoperative stay among same-day discharges: 2.27 versus 3.97 hours.

  • PACU issues were lower at ASCs, including hypotension, nausea and vomiting, somnolence, and anxiety.

  • PACU narcotic use was lower at ASCs.

  • Thirty-day complications, readmissions, and return to OR were not significantly different.

• Cost:

  • Estimated ASC facility fees for 99 patients: $1,132,380.

  • Estimated HOPD facility fees for the same cases: $2,917,876.

  • Estimated savings: $1,785,496, or 61.2%.

Conclusion

For selected patients undergoing implant-based immediate reconstruction, same-day mastectomy at an ambulatory surgery center appears feasible and short-term safe, with substantial facility-level cost savings. The clearest modifiable operational signal is timing: morning scheduling and avoidance of late PACU arrival may meaningfully reduce unexpected admission.

Strengths and limitations

• Large contemporary cohort focused specifically on mastectomy with immediate implant or tissue expander reconstruction.

• Direct comparison of ASC and HOPD settings with real operational outcomes and modeled cost data.

• Retrospective, single-system design with important selection bias; ASC patients were preselected and could not stay overnight at the center.

• Surgeons practiced across limited sites, so site effects may partly reflect surgeon or team behavior rather than facility type.

• Cost analysis used Medicare facility-fee estimates and excluded professional fees, downstream utilization, and transfer logistics.

• No patient-reported outcomes, satisfaction data, or longer-term reconstructive outcomes were assessed.

Clinical relevance

This paper supports a structured pathway with regional anesthesia, multimodal analgesia, aggressive antiemetic strategy, and deliberate morning scheduling. Patients who are older, live farther away, or are having bilateral surgery merit more careful site selection and stronger counseling about the chance of overnight admission. In practice, the paper supports moving selected direct-to-implant and tissue expander cases to ASCs, but only if the center has experienced breast and plastic surgery teams, reliable escalation pathways, and a culture optimized for same-day discharge.

Context within the literature

• American Society of Breast Surgeons Working Group, 2022: The specialty review supports home recovery after mastectomy when patient selection, education, analgesia, and rescue pathways are standardized. This current study fits that framework and provides a more granular site-of-care comparison.

• Specht et al., 2022: In this same Massachusetts General Hospital program, implementation of a same-day reconstruction pathway reduced median stay from 24.6 to 5.5 hours without increasing 30-day readmissions. The current paper is the operational next step, showing further compression of stay and extension into ASCs.

• Vuong et al., 2021: In a large integrated system, 64% of mastectomies were outpatient. Immediate reconstruction and ASA 3 to 4 decreased the odds of outpatient recovery, and 7% of outpatients had return-to-care within 7 days. Compared with that broader cohort, the present paper focuses only on reconstructed patients and highlights distance, bilateral surgery, and late-day recovery as the strongest practical barriers.

• Caminiti et al., 2024: In a planned same-day mastectomy cohort, postoperative admission was predicted by preoperative opioid use, ASA status, longer PACU stay, and start time after noon, with higher costs for those admitted. The present study strongly confirms the timing signal and extends it to reconstructed patients.

• Brantley et al., 2023: NSQIP analysis of more than 21,000 immediate implant-based reconstructions showed similar wound complications and lower readmission with same-day discharge versus admission. That national dataset supports the safety signal seen here.

• Schwartz et al., 2020: Prepectoral reconstruction in an ASC had similar overall complications and lower major infectious complications than hospital-based care. The current paper did not reproduce a lower infection signal, but it did show equivalent short-term safety with faster recovery and lower estimated cost.

• Kauke-Navarro et al., 2025: A 15-year NSQIP analysis of direct-to-implant reconstruction found same-day discharge was associated with lower adjusted odds of complications, reoperation, and readmission in selected patients. This newer national literature strengthens the argument that carefully selected implant-based mastectomy patients do not need routine overnight admission.

Editorial Notes

• The most important limitation is confounding by selection and system design. ASC patients were preselected for lower anesthetic risk and all ASC cases were scheduled in the morning, so the paper cannot isolate whether the better PACU profile is due to the ASC itself or simply who and when the center operated.

• A 100% same-day discharge rate at ASCs is impressive, but it may partly reflect the fact that these centers have no overnight capability. That operational constraint may bias toward discharge rather than prove every discharge was equally appropriate.

• The paper evaluates 30-day surgical safety, but not patient-centered recovery. We still do not know whether pain control, sleep, drain management confidence, or satisfaction differed by site.

• Five hematomas required takeback within 24 hours, and three occurred after discharge. That number is not alarming, but it reinforces that outpatient pathways must be paired with excellent triage, patient education, and rapid access to re-evaluation.

• The cost analysis is useful for administrators, but it is based on Medicare facility-fee estimates and excludes physician reimbursement, caregiver burden, ambulance transfers from ASC to hospital, and indirect costs.

  • In general, shifting cases to lower-acuity centers produces the greatest savings for payers/insurers, although professional fees may be somewhat higher in those settings.  Bottom line