title: Optimizing Efficiency in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.
abstract: BACKGROUND
  The process of harvesting and performing microsurgical anastomosis in a deep inferior epigastric perforator (DIEP) flap for breast reconstruction can be a lengthy procedure, which could affect outcomes and patient safety. We hypothesize that the implementation of a high volume center, preoperative planning, and the adaptation of key intraoperative components will optimize the efficiency of perforator flap surgery for breast reconstruction.
  
  
  METHODS
  A retrospective review of 68 consecutive patients who underwent 104 DIEP flaps for immediate or delayed breast reconstruction was performed. Standardized preoperative planning, including computed tomography/magnetic resonance imaging angiogram, operating room setup, and operative technique, was followed. The times of flap harvest, internal mammary vessel harvest, microsurgical anastomosis, flap inset, wound closure, and total length of procedure were reviewed as well as patient outcomes.
  
  
  RESULTS
  The average length of surgery for a unilateral DIEP was 3 hours and 21 minutes and for a bilateral DIEP was 5 hours and 46 minutes. In bilateral DIEP flaps, a significantly longer operative time was noted in immediate (363 ± 14 minutes) compared to delayed (296 ± 17 minutes) (P < 0.05) reconstruction and between procedures performed by 1 surgeon (400 ± 29 minutes) versus 2 surgeons (326 ± 11 minutes) (P < 0.05). Interestingly, no significant difference in operative time was seen in DIEP flaps performed on patients with a body mass index (BMI) less than 30 (193 ± 7.6, 352 ± 17 minutes) versus a BMI greater than 30 (213 ± 11, 333 ± 14 minutes) in both unilateral and bilateral procedures, respectively.
  
  
  CONCLUSIONS
  Efficiency is optimized by preoperative planning with computed tomography/magnetic resonance imaging angiogram, a dedicated operating room team, including 2 microsurgeons and a systematic approach for surgery. The BMI may not significantly affect the duration of surgery.
authors.affiliation: From the *Division of Plastic and Reconstructive Surgery, Tulane University, New Orleans; and †Division of Plastic and Reconstructive Surgery, Louisiana State University, Baton Rouge, LA.
authors.forename: Orlando
authors.initials: O
authors.lastname: Canizares
authors.forename: James
authors.initials: J
authors.lastname: Mayo
authors.forename: Eliana
authors.initials: E
authors.lastname: Soto
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Allen
authors.forename: Alireza
authors.initials: A
authors.lastname: Sadeghi
mesh_terms: D000328:Adult; D000368:Aged; D004526:Efficiency; D019074:Epigastric Arteries / Q000637:transplantation*; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply / Q000637:transplantation*; D061847:Hospitals, High-Volume; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D061646:Operative Time; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*; D061525:Perforator Flap / Q000098:blood supply / Q000637:transplantation*; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies