The Impact of Intraoperative Methadone on Perioperative Opioid Requirements in Autologous Free Flap Breast Reconstruction

Background: The use of intraoperative methadone has received considerable attention due to reports of reduced postoperative pain and opioid consumption without increased risk of opioid-related side effects. The purpose of this study was to compare perioperative opioid requirements in patients who received intraoperative methadone to those who did not receive intraoperative methadone following free flap breast reconstruction (FFBR). Methods: A retrospective review of patients who underwent FFBR from July 2023 to August 2024 was performed. Patients were stratified into an intraoperative methadone and non-intraoperative methadone cohort. Patient demographics, operative characteristics, hospital length of stay (LOS), and perioperative opioid consumption per patient were collected. The primary outcome was daily postoperative opioid requirements, recorded in morphine milligram equivalents (MME). Results: A total of 112 patients who underwent FFBR breast reconstruction were identified, 54 in the intraoperative methadone cohort and 58 in the non-intraoperative methadone cohort. Mean opioid consumption was significantly less for the methadone cohort intraoperatively (23.7±13.7 MME vs. 44.5±18.8 MME, p<0.01), on postoperative day (POD) 1 (29.04±28.9 MME vs. 44.4±37.9 MME, p=0.04), POD-2 (22.9±25.7 MME vs. 38.7±38.2 MME, p=0.04), and overall throughout hospitalization compared to the non-intraoperative methadone patients (87.4±87.1 vs. 139.1±121.2; p=0.03). Conclusion: Intraoperative methadone significantly reduces inpatient opioid use after undergoing autologous breast reconstruction on POD-1, POD2, and overall throughout hospitalization. Our findings support the need for well-designed prospective trials to further assess the effectiveness of intraoperative methadone in managing perioperative pain and reducing opioid use during FFBR.