Single versus Multiple Perforator Flaps in Autologous Breast Reconstruction: A Regression Analysis of Clinical...

Perforator selection in free flap breast reconstruction is complex, often involving both preoperative imaging and clinical examination. The number of perforators selected for flap design has classically been analyzed as a tradeoff between donor-site morbidity, flap perfusion, and operative time.

A retrospective review was performed of 258 consecutive abdominal autologous breast reconstruction patients, stratified by laterality and single- versus multiple-perforator flaps. Primary outcomes were operating time, length of stay, daily/total opioid use, flap loss, fat necrosis, and hernia/bulge. Financial metrics analyzed included charges, total cost, and estimated margin.

While controlling for bilateral and unilateral reconstruction, each additional perforator added an average of 27.6 minutes of operating time ( P > 0.001), 0.22 days length of stay ( P = 0.011), and 16.2 morphine milligram equivalents of total opioid use ( P = 0.021). The likelihood of flap thrombosis, flap loss, fat necrosis, or hernia/bulge was similar between single- and multiple-perforator cohorts. Each additional perforator added $4591 in charges ( P = 0.033) and $1425 in total cost ( P = 0.013), and decreased estimated margin by $2717 ( P = 0.010).

These results demonstrate equivalent donor- and recipient-site clinical outcomes between single- versus multiple-perforator flaps. This likely reflects the surgeons' approach to balanced flap designs that prioritize adequate flap perfusion and attempt to limit excess abdominal dissection. When multiple perforators are indicated, operating time, length of stay, and morphine milligram equivalent use increase accordingly. The financial impact of this is not insignificant and warrants consideration.