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

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 sub-three-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.