title: Performing two DIEP flaps in a working day: an achievable and reproducible practice.
abstract: BACKGROUND
  While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day.
  
  
  METHODS
  A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14).
  
  
  RESULTS
  Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004).
  
  
  CONCLUSIONS
  Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.
authors.affiliation: Department of Plastic Surgery, Uppsala Clinic Hospital, Uppsala 75185, Sweden. rafael.acosta.rojas@akademiska.se
authors.forename: Rafael
authors.initials: R
authors.lastname: Acosta
authors.forename: Morteza
authors.initials: M
authors.lastname: Enajat
authors.forename: Warren M
authors.initials: WM
authors.lastname: Rozen
authors.forename: Jeroen M
authors.initials: JM
authors.lastname: Smit
authors.forename: Marcus J D
authors.initials: MJ
authors.lastname: Wagstaff
authors.forename: Iain S
authors.initials: IS
authors.lastname: Whitaker
authors.forename: Thorir
authors.initials: T
authors.lastname: Audolfsson
mesh_terms: D000328:Adult; D000368:Aged; D019074:Epigastric Arteries; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000098:blood supply / Q000637:transplantation*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome; D016526:Workload / Q000706:statistics & numerical data*