Minutes that Matter? The Significance of Operative Time in Immediate Unilateral and Bilateral Free Flap Breast...

Free flap breast reconstruction (FFBR) offers substantial benefits after mastectomy. However, the impact of operative time on outcomes remains unclear.

In this retrospective cohort study, the American College of Surgeons National Surgical Quality Improvement Program database (2011-2022) was queried for patients undergoing immediate FFBR. Multivariate logistic regression assessed operative time as both a continuous and dichotomous variable. Thresholds for operative duration were determined using receiver operating characteristic (ROC) analysis and Youden's Index.

Of 5826 patients, 61% underwent unilateral and 39% bilateral FFBR. Complications occurred in 27% of cases-25% in unilateral and 30% in bilateral procedures. In unilateral FFBR, prolonged operative time was significantly associated with increased risks of overall complications (OR 1.0020 per minute, P < .001), surgical (OR 1.0023, P < .001) and medical complications (OR 1.0019, P = .0011), reoperation (OR 1.0011, P = .013), and readmission (OR 1.0014, P = .0030). Each additional hour increased overall complication risk by 12%, with a 397-minute threshold identified (OR 1.8, P < .001). For bilateral FFBR, longer operative time correlated with higher odds of overall complications (OR 1.0012 per minute, P < .001), surgical complications (OR 1.0012, P = .0014), and reoperation (OR 1.0010, P = .026). A 7.2% increase in adverse event risk was noted per additional hour, with 536 minutes as a critical threshold (OR 1.6, P < .001).

Prolonged operative time significantly increases complication risk in FFBR. Patients with procedures exceeding 397 and 536 minutes were 80% and 60% more likely to experience adverse events, respectively. These findings highlight the need to maximize surgical efficiency and minimize postoperative morbidity.