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

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

[PATIENTS AND METHODS] 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.

[RESULTS] 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).

[CONCLUSION] 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.