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 total of 263 patients underwent immediate or delayed DIEP free flap breast reconstruction from February 2013 to July 2020 by the senior author. Following application of inclusion/exclusion criteria, 128 patients were included in the study. Of these patients, 21 had immediate reconstruction, and 107 had 2-staged/delayed reconstruction. There was no significant difference in patient characteristics between immediate and delayed reconstruction (Table 1).

Immediate/1-stage Flap Reconstruction Patients

Within the 21 immediate reconstruction patients, 6 underwent unilateral flap reconstruction, and 15 underwent bilateral flap reconstruction. Average operative (OR) times were 427.0 minutes for unilateral mastectomy/unilateral reconstruction, and 506.3 minutes for bilateral mastectomy/bilateral reconstruction (Table 2).

Delayed/2-stage Flap Reconstruction Patients

Within the 107 delayed reconstruction patients, 23 were unilateral single flap reconstructions, and 84 were bilateral flap reconstructions. Of these patients, 51 had tissue expanders placed by the senior surgeon for which operative times were available, 15 of whom were unilateral, and 36 of whom were bilateral. Of the 51 tissue expander placements, 9 (18%) developed complications. Average OR for tissue expander placement was 62.20 minutes when done unilaterally, and 64.00 minutes when done bilaterally (Table 2). Considering the 107 delayed DIEP flaps performed in the study period, the average operative time for a delayed unilateral DIEP was 288.9 minutes, and for a bilateral DIEP was 400.8 minutes. Average combined operative times for the plastic surgeon employing a 2-stage approach was 351.1 minutes for unilateral expander/delayed DIEP flap, and 464.8 minutes for bilateral expander/delayed DIEP flap (Table 2). On comparison, the combined plastic surgeon's operative time for delayed unilateral single flap reconstruction was significantly shorter than immediate unilateral reconstruction by 75.90 minutes (P = 0.007); and the combined time for delayed bilateral flap reconstruction was significantly shorter than immediate bilateral reconstruction by 41.50 minutes (P = 0.045) (Table 2).

Total Patient Time Under Anesthesia

The total patient time was also recorded in Table 2. The average mastectomy and tissue expander placement time was 142.4 minutes when done unilaterally (n = 15), and 204.7 minutes when done bilaterally (n = 36). Thus, for delayed reconstruction, total patient time under anesthesia was 431.3 minutes for unilateral single flap, and 605.5 minutes for bilateral flaps. Total patient time in immediate reconstruction was the same as the previously reported plastic surgeon time. On analysis, the total patient time was shown to be significantly longer (99.20 minutes) for delayed bilateral reconstruction in comparison with immediate bilateral reconstruction (P = 0.0001) (Table 2). However, no significant difference was noted in the unilateral reconstructive procedures (427 minutes (immediate) versus 431.3 minutes (delayed), P = 0.87).

Takebacks and Complications

All patients receive 30 milligrams of Lovenox twice a day for prophylactic anticoagulation. A total of 4 takebacks were recorded—1 for immediate reconstruction (4.76%), and 3 for delayed reconstruction (2.80%). Flap salvage was obtained for 2 of 4 takebacks with surgical intervention and 5000 I.U. Heparin intravenous bolus. One flap loss occurred for each immediate (4.76%) and delayed (0.93%) subgroup, with no significant difference noted on statistical analysis (Table 3 and Table 4).