Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

Abstract

Introduction:The DIEP flap is considered the gold standard in autologous breast reconstruction. Despite the benefit of a lifelong natural reconstruction, some argue that the potential drawbacks, specifically operative time and recovery, are significant. We recently focused specifically on process analysis in our DIEP flap practice and present a comprehensive analysis in efficient DIEP flap breast reconstructions. Methods: Fifty consecutive bilateral DIEP flaps were prospectively tracked (100 flaps). The procedure was divided into segments (recipient site preparation, DIEP flap dissection/harvest, microsurgery, breast shaping, and abdominal closure). All individual step times were recorded for each team member. Relevant patient characteristics, intraoperative details and postoperative outcomes were recorded. Results: Average surgical time was 3 hours and 58 minutes (the fastest time recorded was 2 h and 14 min). There were no immediate postoperative complications. The anastomotic revision rate was 6%. Four surgeons contributed 34.7% of the time, three surgeons 32.2% of the time, two surgeons 23.6% of the time, and one surgeon 4.8% of total time. In procedures under 4 hours, four surgeons contributed simultaneously 36.7% of the time compared to 21.8% in the longer procedures (P = 0.004). Four surgeons contributed 45.4% of the time (P = 0.01) in the subthree-hour bilateral DIEP flap procedures. Conclusions: Efficient DIEP flap breast reconstruction can be accomplished with a well-trained and coordinated team approach involving like-minded surgeons with extensive experience working together. The synergistic map shows constant movement with utilization of hidden time, without sacrificing education, outcomes, or innovation.

Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis

“…Rigorous process analysis of critical maneuvers, identifying inefficient operative steps, and a team-based approach have been shown to significantly reduce OT. [31][32][33] A co-surgery attending model has also been demonstrated to decrease OT, postoperative morbidity, and LOS. 34 Additionally, utilizing preoperative imaging, such as computerized tomography angiography, has been shown to decrease the duration of operative steps, specifically with perforator identification and decision making.…”

Literature Review

“…In an era where team-based microsurgery is accomplishing 4-hour bilateral DIEP flap reconstruction, the added operative time associated with the robotic platform may not be palatable for many hospital systems 32 . Furthermore, the docking of the robot makes it challenging for multiple teams to simultaneously operate, thus further adding operative time and decreasing efficiency.…”

“…30,31 In an era where team-based microsurgery is accomplishing 4-hour bilateral DIEP flap reconstruction, the added operative time associated with the robotic platform may not be palatable for many hospital systems. 32 Furthermore, the docking of the robot makes it challenging for multiple teams to simultaneously operate, thus further adding operative time and decreasing efficiency. As an illustration, Choi et al 16 shared a series of 17 patients in which a robotic TEPP deep inferior epigastric vessel harvest was used after a suprafascial dissection was already performed in the open fashion.…”

Recent advances in surgical techniques for breast reconstruction

“…It is especially useful for reconstruction in women with a hereditary risk of breast and ovarian cancer who underwent bilateral risk reducing mastectomy, as it allows for simultaneous bilateral breast reconstruction in which one flap is divided into two (Fig. 1c) [11]. Other breast reconstruction methods using a free superficial inferior epigastric artery (SIEA) flap with the superficial inferior epigastric artery/vein running in the superficial subcutaneous layer as a nutrient vessel have also been reported [12,13] (Fig.…”