Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Issa, Christopher; Lu, Stephen; Boudiab, Elizabeth; DeSano, Jeffrey; Sachanandani, Neil S.; Powers, Jeremy M.; Chaiyasate, Kongkrit

doi:10.1097/gox.0000000000003608

Cited by 9 publications

(12 citation statements)

References 23 publications

(30 reference statements)

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“…One of the disadvantages of surgically delaying TDAP flaps is that this requires 2 operations, increasing hospital stay and surgical course. However, the total operative time to surgically delay the TDAP flap and reconstruct the unilateral breast with either no concurrent procedures or concurrent capsulectomy only in this series is 313 ± 30 minutes (n = 7 flaps) with 2 surgeons, which is comparable to the total duration of DIEP flap breast reconstruction cases 39,40 . It is well-documented that free flap breast reconstruction often requires access to microsurgical expertise, longer hospital stay, and additional resources for inpatient floor or intensive care unit flap monitoring 41–43 .…”

Section: Discussionmentioning

confidence: 76%

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

Maier,

Hoffman,

Kordahi

et al. 2024

Ann Plast Surg

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Background When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction. Methods Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days). Results Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations). Conclusions We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

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Section: Discussionmentioning

confidence: 76%

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

Maier,

Hoffman,

Kordahi

et al. 2024

Ann Plast Surg

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“…8 25 26 27 28 Synergistic co-surgery models have been demonstrated as a safe method of reducing operative time in autologous breast reconstruction. 8 25 26 Rigorous process analysis incites continual assessments in improving surgical flow and employment of hidden time. 8 29 30…”

Section: Discussionmentioning

confidence: 99%

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

Wen,

Steppe,

Teotia

et al. 2023

J Reconstr Microsurg

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Introduction 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). Conclusions 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.

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“…The flaws of the RVU system have been shown to influence surgical decisions across specialties, affecting patient outcomes of all disciplines. 8,[20][21][22][23] These concerns may be reflected in the popularity of carve-outs (reimbursement agreements that exceed the gross recipient indicated by Medicare) and use of Healthcare Common Procedure Coding System codes in microsurgical breast reconstruction. Carve-outs, however, may facilitate additional inequities in reimbursement.…”

Section: Discussionmentioning

confidence: 99%

“…This allowed us to identify operative times for individual CPT codes and avoid the confounding effects of co-surgery cases, which are common in plastic surgery. Data supporting this decision have been presented by Issa et al, 8 who showed statistically significant reductions in operative times performing breast free flaps in a planned staged fashion rather than immediate.…”

Section: Case Selectionmentioning

confidence: 92%

“The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties”

Shim

Stoffel

Neubauer

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Background: The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery. Methods: A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20. Results: Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction. Conclusions: Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

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Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Cited by 9 publications

References 23 publications

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

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

“The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties”

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