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Co-surgeons in Breast Reconstructive Microsurgery: Is There Strength in Numbers?
Samar Kayfan, B.A., Ronnie A. Pezeshk, M.D., Nikitha K. Reddy, B.A., Madeline A. Cullins, B.A., Andrew A. Gassman, M.D., Sumeet S. Teotia, M.D., Nicholas T. Haddock, M.D..
University of Texas Southwestern Medical Center, Dallas, TX, USA.

Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes.1-4 Co-surgery has yet to be evaluated in free flap autologous breast reconstructive surgery regarding operative efficiency, patient, and surgical outcomes.
Methods:A retrospective review of free-flap breast reconstruction at UT-Southwestern University Hospital from 2010-2015 was conducted. From the database, we analyzed 108 patients who only underwent bilateral-DIEP breast reconstruction (216 flaps). We analyzed three surgical groups for two breast micro-surgeons: single-surgeon reconstruction (SSR), Co-Surgery where both surgeons are present for entire reconstruction (CSR-I), and Co-Surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II). Efficiency data collected: OR time (plastic surgery start-to-end), patient length-of-stay (LOS), flap-failure rate, return to operating room, and timing of surgery (immediate vs delayed-immediate). For surgical outcomes, we compared rates of infection, wound breakdown, seroma, hematoma and tissue necrosis for abdominal donor, breast recipient, and umbilical sites. For patient outcomes, we examined rates of PE/DVT and wound care with VAC. Outcome data was analyzed via unpaired two-tailed student’s t-test and Chi-square analysis for patient demographic data (statistical significance P<0.05).
Results: Single-surgeon reconstruction had significantly longer average OR time (685minutes vs 498minutes), average LOS (5days vs 3.9days), and higher umbilical wound complications (15%
vs 2%) compared to CSR-I. Similarly, SSR had significantly longer average OR time (685minutes vs 538minutes), average LOS (5days vs 3.8days) when compared to CSR-II. There were no increased patient related complications associated with Co-surgery (CSR- I or II). These efficiency benefits occurred despite both co-surgery groups having increased comorbidities such as significantly higher average BMI values.
Conclusion:The addition of a Co-surgeon, even with concurrent surgery, potentially limits operative time , average patient length of stay and some post-operative complications. Although derived from retrospective analysis this work suggests that the Co-surgery model is associated with increased operative efficiency for Bilateral DIEP Breast Reconstruction.
1. Tomlinson JE, Hannon E, Sturdee S, London N. Bilateral simultaneous two surgeon knee replacement surgery. J Bone Joint Surg Br. 2009;91-B(SUPP I):43. 

2. Aloia TA, Zorzi D, Abdalla EK, Vauthey JN. Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection. Ann Surg. 2005;242:172-7. 

3. Arlow RL, Moore DF, Chen C, Langenfeld J, August DA. Out- come-volume relationships and transhiatal esophagectomy: minimizing ‘‘failure to rescue’’. Ann Surg Innov Res. 2014;8:9. 

4. Tomlinson J, Hannon E, Sturdee S, London N. Bilateral simultaneous two surgeon knee replacement surgery. J Bone Joint Surg Br. 2009;91:43. 

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