Background: Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in deep inferior epigastric artery perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Methods: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5–7 hours had comparable odds (P = 0.540), and 7–9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001). Conclusions: OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

Background: Umbilectomy has been implemented in both abdominoplasties and deep inferior epigastric perforator (DIEP) flaps to improve abdominal wound healing and better control the location of the neo-umbilicus; however, seroma rates are increased. The objective of this study is to compare the seroma rate following DIEP flap reconstruction with umbilectomy when progressive tension sutures (PTS) are implemented. Methods: A retrospective chart review was performed to evaluate post-operative seroma rates in patients undergoing DIEP flap breast reconstruction at a single academic institution between January 2015 and September 2022. All procedures were performed by two senior surgeons. Patients were included if their umbilicus was removed intraoperatively. PTS were utilized in all abdominal closures beginning in late February 2022. Demographics, comorbidities, and post-operative complications were evaluated. Results: Two Hundred and forty-one patients underwent DIEP flap breast reconstruction with intraoperative umbilectomy. Forty-three consecutive patients received PTS. Overall complications were significantly lower in those who received PTS (p = 0.007). There were no abdominal seromas (0%) in patients who received PTS while fourteen (7.1%) occurred without PTS. The use of PTS conferred a decreased likelihood of abdominal seroma (5.687x lower risk, p = 0.017). Additionally, wound formation was significantly lower in those who received PTS (p = 0.031). Conclusion: The use of PTS in the abdominal closure during DIEP flap reconstruction addresses the previously seen rise in seroma rates when concomitant umbilectomy is performed. Decrease in both donor site wounds and now seroma rates reaffirm the efficacy of removing the umbilicus to improve patient outcomes.

No abstract