J Reconstr Microsurg 2024; 40(03): 217-226
DOI: 10.1055/a-2133-1018
Original Article

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction

1   University of Texas Southwestern Medical Center, Medical School, Dallas, Texas
,
Cyrus Steppe
1   University of Texas Southwestern Medical Center, Medical School, Dallas, Texas
,
Sumeet S. Teotia*
2   Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
,
Nicholas T. Haddock*
2   Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
› Institutsangaben

Abstract

Background The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity.

Methods Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity.

Results Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05).

Conclusion Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Presented at

American Association of Plastic Surgeons (AAPS) 2023 Annual Meeting in Chicago, Illinois.


* The authors should be regarded as co-corresponding and co-senior authors.


Supplementary Material



Publikationsverlauf

Eingereicht: 18. Februar 2023

Angenommen: 17. Juli 2023

Accepted Manuscript online:
19. Juli 2023

Artikel online veröffentlicht:
11. September 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Cheng H, Chen BP, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration increases risk of surgical site infections: a systematic review. Surg Infect (Larchmt) 2017; 18 (06) 722-735
  • 2 Hardy KL, Davis KE, Constantine RS. et al. The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J 2014; 34 (04) 614-622
  • 3 Kwok AC, Edwards K, Donato DP. et al. Operative time and flap failure in unilateral and bilateral free flap breast reconstruction. J Reconstr Microsurg 2018; 34 (06) 428-435
  • 4 Haddock NT, Wen YE, Steppe C, Shang Z, Teotia SS. Operative time predicts postoperative outcomes in bilateral DIEP flap reconstruction: multivariate 1000 flap analysis. Plast Reconstr Surg Glob Open 2022; 10 (12) e4713
  • 5 Statistics ANCoPSP. 2020 Plastic Surgery Statistics Report. American Society of Plastic Surgeons; 2020. Accessed August 2, 2023 at: https://www.plasticsurgery.org/documents/News/Statistics/2020/plasticsurgery-statistics-full-report-2020.pdf
  • 6 Khajuria A, Prokopenko M, Greenfield M, Smith O, Pusic AL, Mosahebi A. A meta-analysis of clinical, patient-reported outcomes and cost of DIEP versus implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2019; 7 (10) e2486
  • 7 Opsomer D, D'Arpa S, Benmeridja L, Stillaert F, Noel W, Van Landuyt K. Bilateral DIEP flap breast reconstruction to a single set of internal mammary vessels: technique, safety, and outcomes after 250 flaps. Plast Reconstr Surg 2019; 144 (04) 554e-564e
  • 8 Haddock NT, Teotia SS. Efficient DIEP flap: bilateral breast reconstruction in less than four hours. Plast Reconstr Surg Glob Open 2021; 9 (09) e3801
  • 9 Toyserkani NM, Jørgensen MG, Tabatabaeifar S, Damsgaard T, Sørensen JA. Autologous versus implant-based breast reconstruction: a systematic review and meta-analysis of Breast-Q patient-reported outcomes. J Plast Reconstr Aesthet Surg 2020; 73 (02) 278-285
  • 10 Halani SH, Jones K, Liu Y, Teotia SS, Haddock NT. Reconstructive burnout after mastectomy: implications for patient selection. Plast Reconstr Surg 2023; 151 (01) 13e-19e
  • 11 Bennett KG, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 901-908
  • 12 Haddock NT, Culver AJ, Teotia SS. Abdominal weakness, bulge, or hernia after DIEP flaps: An algorithm of management, prevention, and surgical repair with classification. J Plast Reconstr Aesthet Surg 2021; 74 (09) 2194-2201
  • 13 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
  • 14 Haddock NT, Garza R, Boyle CE, Teotia SS. Observations from implementation of the ERAS protocol after DIEP flap breast reconstruction. J Reconstr Microsurg 2022; 38 (06) 506-510
  • 15 Hembd A, Teotia SS, Zhu H, Haddock NT. Optimizing perforator selection: a multivariable analysis of predictors for fat necrosis and abdominal morbidity in DIEP flap breast reconstruction. Plast Reconstr Surg 2018; 142 (03) 583-592
  • 16 Howland WS, Schweizer O. Complications associated with prolonged operation and anesthesia. Clin Anesth 1972; 9 (01) 1-7
  • 17 Kim BD, Ver Halen JP, Grant DW, Kim JY. Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases. J Reconstr Microsurg 2014; 30 (04) 217-226
  • 18 Kotha VS, Abadeer AI, Amdur RL, Song DH, Fan KL. A critical examination of length of stay in autologous breast reconstruction: a National Surgical Quality Improvement Program analysis. Plast Reconstr Surg 2021; 147 (01) 24-33
  • 19 Kwok AC, Agarwal JP. Unplanned reoperations after microvascular free tissue transfer: an analysis of 2,244 patients using the american college of surgeons national surgical quality improvement program database. Microsurgery 2017; 37 (03) 184-189
  • 20 Butler DP, Plonczak AM, Reissis D. et al. Factors that predict deep inferior epigastric perforator flap donor site hernia and bulge. J Plast Surg Hand Surg 2018; 52 (06) 338-342
  • 21 Vanschoonbeek A, Fabre G, Nanhekhan L, Vandevoort M. Outcome after urgent microvascular revision of free DIEP, SIEA and SGAP flaps for autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1598-1608
  • 22 Mahmoudi E, Lu Y, Chang SC. et al. Associations of surgeon and hospital volumes with outcome for free tissue transfer by using the National Taiwan Population Health Care data from 2001 to 2012. Plast Reconstr Surg 2017; 140 (03) 455e-465e
  • 23 Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JY. Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients. Ann Plast Surg 2013; 71 (04) 335-341
  • 24 Offodile II AC, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017; 37 (01) 12-20
  • 25 Issa CJ, Lu SM, Boudiab EM. et al. Comparing plastic surgeon operative time for DIEP flap breast reconstruction: 2-stage more efficient than 1-stage?. Plast Reconstr Surg Glob Open 2021; 9 (06) e3608
  • 26 Haddock NT, Kayfan S, Pezeshk RA, Teotia SS. Co-surgeons in breast reconstructive microsurgery: what do they bring to the table?. Microsurgery 2018; 38 (01) 14-20
  • 27 Canizares O, Mayo J, Soto E, Allen RJ, Sadeghi A. Optimizing efficiency in deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2015; 75 (02) 186-192
  • 28 Haddock NT, Teotia SS. Five steps to internal mammary vessel preparation in less than 15 minutes. Plast Reconstr Surg 2017; 140 (05) 884-886
  • 29 Sharma HR, Rozen WM, Mathur B, Ramakrishnan V. 100 steps of a DIEP flap-a prospective comparative cohort series demonstrating the successful implementation of process mapping in microsurgery. Plast Reconstr Surg Glob Open 2019; 7 (01) e2016
  • 30 Haddock NT, Teotia SS. Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps. Plast Reconstr Surg 2020; 145 (04) 717e-724e
  • 31 Yoon AP, Qi J, Brown DL. et al. Outcomes of immediate versus delayed breast reconstruction: results of a multicenter prospective study. Breast 2018; 37: 72-79