Achieving Textbook Outcomes in Bilateral DIEP Flap Breast Reconstruction: Does a Co-Surgeon Matter?

Abstract

Background

It is essential to examine predictors of ideal outcomes in surgery. “Textbook outcomes” are optimal surgical results based on multiple quality measures. It is important that patients have access to trusted centers that consistently produce high-quality surgical outcomes.

Methods

A retrospective review of all bilateral Deep Inferior Epigastric Perforator (DIEP) flap breast reconstructions at our institution from 2017 to 2022 was performed. Criteria for “textbook outcome” were operating room (OR) time within one standard deviation of institutional average or less, length of stay ≤ 4 days, no intraoperative complications, no operative complications, no readmission within 30 days, no infection requiring IV antibiotics, no systemic complications, and no mortality. Propensity score matching was used to control for common comorbidities, reconstruction timing, and oncologic factors. This resulted in 47 matched pairs of bilateral DIEP flap reconstructions for comparison between a single-surgeon cohort and a co-surgeon cohort.

Results

Textbook outcomes occurred at a significantly higher rate in the co-surgeon cohort compared with the single surgeon cohort (79% vs. 57%, p = 0.025). The average OR time was significantly shorter in the co-surgeon cohort compared with the single surgeon cohort (403 minutes vs. 572 minutes, p < 0.0001), and elevated OR time was the most common reason for not achieving a textbook outcome. There were no differences in the other criteria for a “textbook outcome.”

Conclusion

Textbook outcomes in bilateral DIEP flap breast reconstruction are achieved at significantly higher rates with a co-surgeon. This is primarily due to significantly shorter OR times. Further research into factors affecting textbook outcomes is needed.

Keywords

breast reconstruction - co-surgeon - textbook outcome

Presented at (if applicable):

1. Oral Presentation at Virginia Society of Plastic Surgeons Meeting 2024. October 19, 2024. White Sulphur Springs, West Virginia, USA.

2. Poster Presentation Southeastern Society of Plastic and Reconstructive Surgery Annual Scientific Meeting Medical Student Poster Competition 2024. Virtual Format. April 10, 2024.

3. Oral Presentation at Plastic Surgery The Meeting 2024. September 28, 2024. San Diego, California, USA.

Publication History

Received: 22 March 2025

Accepted: 27 July 2025

Accepted Manuscript online:
31 July 2025

Article published online:
21 August 2025

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