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


Optimization of DIEP flap breast reconstruction has become a main focus for plastic surgeons. Through advancements in operative techniques, equipment, and postoperative care pathways, experienced microsurgeons are now able to perform DIEP flap reconstruction with highly aesthetic outcomes and shorter recovery times.[13,19] Despite these advances, concerns persist from patients, referring surgeons, and plastic surgeons regarding the relatively long operative time needed to complete the surgery.

The primary objective of our study was to compare the plastic surgeon's operative time between immediate DIEP flap reconstruction at the time of mastectomy with a 2-stage strategy involving initial expander placement followed by delayed DIEP flap reconstruction. A secondary objective of the study was to compare a patient's total time under anesthesia with the 2 different surgical protocols, as well as postoperative flap complications. Through our retrospective study, the 2-stage immediate expander/delayed DIEP flap was more efficient with respect to the plastic surgeon's time for both unilateral and bilateral procedures. Total patient time under anesthesia was significantly longer by about 99 minutes for 2-staged bilateral procedures, but did not significantly differ for unilateral procedures. Flap complication rates were low in both groups and did not differ significantly.

Literature has shown that longer operative times result in an increase in probability of complications for every additional 30 minutes under anesthesia.[20] Cheng et al conducted a systematic review analyzing a multitude of surgical specialties, and found that the likelihood of a surgical site infection increased by 17% for every additional 30 minutes, and by 37% for every additional 60 minutes.[21] Furthermore, Mlodinow et al examined over 19,000 general plastic surgery cases and found that longer surgical duration was associated with increased venous thromboembolism rates.[22] Thus, although it has not been studied extensively, it is possible that splitting a long procedure into 2 shorter ones may reduce the risk of surgical complications; however, further research is needed to ensure that the benefit of reducing surgical complications is not erased by the additive increase in anesthetic complications of an additional general anesthetic.

Several recent studies have compared immediate versus 2-staged delayed breast reconstruction flap techniques, with studies reporting relative equivalence in aesthetic outcomes,[23] but lower complication rates in delayed reconstruction.[24] Although patients benefit from a single anesthetic, shorter time under anesthesia, and instant aesthetic results with immediate reconstruction, the disadvantages of a longer operative time, potentially higher risk of complications, and unexpected oncologic findings, represent definite downsides of this approach. There are many advantages of placing an initial expander and returning later for free flap reconstruction including: delaying the mastectomy flap, completing adjuvant therapies, maintaining optimal aesthetic results following postmastectomy radiotherapy,[23] easier scheduling with the breast surgeon, easier accommodation of urgent scheduling needs, a defined pocket for flap inset, the ability to bury the flap with the preserved skin if desired, and plastic surgeon direction of the operating room team. Certainly, tissue expander related complications must be considered in the full analysis of the 2 strategies.

By maximizing efficiency while maintaining patient safety, DIEP flap breast reconstruction can become a suitable option for many postmastectomy patients. Research has shown that patients tend to choose implant-based reconstruction over autologous breast reconstruction due to a smaller surgical impact and shorter recovery times.[19] Thus, by demonstrating that DIEP flap reconstruction can be performed efficiently in a 2-staged delayed fashion, patients who desire autologous reconstruction but are concerned about operative time may be reassured. It is important to note that accomplishing efficient operative time for these complex procedures requires an experienced operating room team which takes time to develop.

Our study demonstrates that 2-stage DIEP flap breast reconstruction is more efficient for the plastic surgeon in both unilateral and bilateral procedures, without significantly prolonging the patient's total time under anesthesia in unilateral reconstruction. However, there were several important limitations of our study. One of these limitations include a relatively small sample size, primarily in the immediate reconstruction group, as most DIEP flap reconstructions at our institution are done in a delayed fashion. Furthermore, our study was inadequately powered to detect complications related to undergoing an additional general anesthetic, nor did we compare long term patient reported outcomes or revision rates between the 2 approaches. Additionally, because our surgical team consisted of a microsurgical fellow and plastic surgery resident, our data are limited to well-established surgical teams that may not be available at most nonacademic practice settings. However, co-attending surgeon models with adequate advanced practice provider support may be an analogous alternative. These are all important considerations and will be a focus of future study in this area.