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


A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction from February 2013 to July 2020 by the senior author. Investigators recorded patient demographics and comorbidities, including age, BMI, smoking status, hypertension, diabetes, coagulation disorders, adjuvant radiation therapy, and adjuvant chemotherapy (Table 1). Patients were separated by unilateral/bilateral mastectomy and immediate or delayed reconstruction. Those who underwent stacked/bipedicled flaps, delayed DIEP flap reconstruction without first-stage tissue expander placement, or bilateral reconstruction in which one breast was reconstructed in a delayed fashion and the other breast was reconstructed in an immediate fashion, were excluded from this analysis.

Because operative times for initial tissue expander surgeries performed at outside facilities were not available, only immediate tissue expander placements performed by the senior author in preparation for DIEP flap reconstruction were included. All immediate DIEP flap reconstructions for the study period from 2013 to 2020 were included, as operating personnel were consistent with attending plastic surgeon, resident or fellow, and first assist present, typically starting at the same time as the breast surgeon. For delayed flap reconstruction, we included patients from March 2016 to July 2020, to reflect consistency of the operative team, which included the attending surgeon and microsurgery fellow raising the flaps, and a plastic surgery resident and advanced practice provider preparing the chest recipient sites, followed by microsurgical anastomosis and inset with simultaneous closure of the abdomen.

Operative time for immediate tissue expander insertion was measured from entry of the plastic surgeon until skin closure, based on times recorded by the circulating nurse in the electronic medical record. The average operative times for unilateral and bilateral tissue expander placements were added to the respective average delayed DIEP flap reconstruction times, to yield the combined two-stage flap reconstruction procedural time (Figure 1). For immediate reconstruction, our institution's norm is for the plastic surgeon to work concurrently with the breast surgeon; therefore, operative time for the whole procedure (mastectomy and DIEP flap) was considered as the plastic surgeon's total operative time (Figure 1). The type of mastectomy and postoperative complications were recorded.

Figure 1.

Schematic diagram for the calculated operative times for both plastic surgeon and patient in each reconstructive subgroup.

Although our primary focus was the operative time required of the plastic surgeon, we also wanted to capture the total patient time under anesthesia. In immediate reconstruction, we considered this time to be equivalent to the plastic surgeon's operative time. In delayed reconstruction, we added the time of the mastectomy to the previously calculated plastic surgeon's time (the time for immediate tissue expander placement plus the delayed DIEP free flap reconstruction) (Figure 1).

For analysis, the plastic surgeon's operative time for 1-stage immediate flap reconstruction was compared with the combined operative time in 2-stage expander followed by delayed flap reconstruction, with groups distinguished by laterality (unilateral versus bilateral). Total patient time under anesthesia was similarly compared between the single-stage and 2-stage groups. Using Microsoft Excel (Redmond, Wash.), descriptive statistics, measures of central tendency, and measures of variability were used to describe absolute, mean, and SD results, respectively. Additionally, using GraphPad QuickCalcs (Graphpad Software, San Diego, Calif.), Fisher's exact test was used to compare patient characteristics (excluding age and BMI) and flap complications, and an unpaired t test was used to compare age, BMI, and operative times. Values of P < 0.05 were considered statistically significant.