Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps

Abstract

Sir: We read with great interest the article by Haddock and Teotia entitled, “Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps.”1 This article shares the authors’ impressive experience with deep inferior epigastric perforator (DIEP) flap breast reconstruction, and we applaud their use of process analysis to enhance operating efficiency with a common yet highly variable procedure. The authors determined eight critical maneuvers focused on flap harvest (n = 5) and microsurgery (n = 3), tracking completion time of bilateral DIEP flap breast reconstruction as the primary outcome. They reported a 73-minute reduction in total operative time in their process-mapping group compared to their control cohort the previous year. Although the authors note that they have included steps considered to be critical and “most technically demanding,” we recommend including two key postanastomotic steps that we believe are equally important: (1) flap inset and (2) flap tailoring. Meticulous flap inset and tailoring are critical to achieving an aesthetic breast reconstruction, the primary goal to which all other steps contribute. Furthermore, this is often when focus dissipates given the significant technical demand of prior steps and near completion of the procedure. Although process mapping focuses on efficiency, it also ensures patient safety and reproducibility of results.2 Once anastomoses are performed and flap inset begins, the perforators and anastomoses are vulnerable to iatrogenic injury, either from mishandling, unintended kinking/twisting, or even misadventures in drain or suture placement.3 Specific decisions and technical steps in flap inset and tailoring can directly correlate with postoperative results and the potential need for secondary revisions.4 Flap inset details include rotation and positioning and ensuring superior pole contouring, particularly medially at the site of rib removal to avoid hollowing.5 The inframammary fold should be maintained or reestablished if inferior migration occurs with tighter closure. Ensuring proper pedicle lie and avoiding kinking can mitigate undue complications.6 Flap tailoring depends on mastectomy type but can include gentle soft-tissue tapering to avoid visible stepoffs. Skin paddle design maintains certain process-oriented principles (e.g., shape, size, and signal monitoring), and circumferential dermal release around the skin paddle is generally beneficial.7 In their discussion, Haddock and Teotia state, “We elected not to include the nonflap time, as the flap inset tends to have much greater variability based on the specifics of the patient and timing of reconstruction.…” We commend the authors for highlighting the patient-specific nature of this surgery. However, there exists significant variability within the eight critical steps outlined. For example, in step 4, “pedicle dissection to groin,” they note “sensory nerves are maintained if sensory coaptation is planned” and if motor nerves are “between two perforators, the nerve is cut and coapted after harvest.” Technical variability and decision-making occurs in each of these steps, not dissimilar to flap inset and tailoring.8 We congratulate the authors on a well-informed study, highlighting critical maneuvers for DIEP flap optimization and efficiency. Attention to postanastomotic steps of flap inset and tailoring should be considered in the next evolution of process mapping and analysis in DIEP flap breast reconstruction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this work. David A. Daar, M.D., M.B.A.Ara A. Salibian, M.D.Jordan D. Frey, M.D.Nolan S. Karp, M.D.Mihye Choi, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone HealthNew York, N.Y.