Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction

2-Stage More Efficient Than 1-Stage?

Christopher J. Issa, BSc; Stephen M. Lu, MD, MDiv; Elizabeth M. Boudiab, MD; Jeffrey DeSano, DO; Neil S. Sachanandani, MD; Jeremy M. Powers, MD; Kongkrit Chaiyasate, MD


Plast Reconstr Surg Glob Open. 2021;9(6):e3608 

In This Article

Abstract and Introduction


Background: The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction.

Methods: A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated.

Results: The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different.

Conclusions: We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.


Breast cancer remains the most common type of nonskin cancer among women today, affecting 1 in 8 women in the United States.[1,2] Interestingly, studies have shown that breast reconstruction is one of the most important factors that can improve a patient's overall well-being following a mastectomy.[3–5] Fortunately, through advancements in silicone implant safety and reconstructive microsurgery, along with the passing of the Woman's Health and Cancer Rights Act in 1998, both implant and tissue-based breast reconstruction have become more accessible and popular over time.[6] Autologous breast reconstruction has specifically been shown to play a pivotal role in postmastectomy treatment plans, as it allows patients to be restored with natural and aesthetically appealing reconstructed breasts.[7] One of the most common flap options, the deep inferior epigastric perforator (DIEP) free flap has been shown to significantly improve patients' long-term breast satisfaction and psychosocial/sexual well-being.[8]

The DIEP flap has remained the gold standard for perforator flap reconstruction due to its consistent anatomy and low morbidity.[9–12] Moreover, with an increase in experienced microsurgeons and enhanced recovery protocols, DIEP flap breast reconstruction has become further refined with shorter postoperative recovery times.[13] Despite higher long-term patient satisfaction in autologous breast reconstruction compared with breast implants,[14–16] implant-based reconstruction remains more common due to shorter operative time, limited availability of microsurgeons, and comparatively favorable insurance reimbursements.[6,17,18]

Several studies have examined the issue of optimizing efficiency of autologous breast reconstruction but were typically performed in the context of immediate reconstruction. In our institution and others, however, 2-stage delayed reconstruction is the norm—a tissue expander is placed at the first stage for preservation of the skin envelope; after expansion and any adjuvant therapies are completed, the expanders are removed and replaced with DIEP flaps in the second stage. The primary objective of this study was to compare the plastic surgeon's operative time and case involvement between DIEP flap reconstruction immediately following mastectomy (single-stage), versus immediate placement of tissue expander(s) followed by delayed DIEP flap reconstruction (2-stage). Secondary objectives included comparing total patient time under anesthesia and overall complications. We hypothesized that the operative time for the plastic surgeon to place tissue expanders and then return at a later date to perform free flap reconstruction would be the same or less than the time required for immediate flap reconstruction at the time of mastectomy.