Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps

Jonlin Chen, Kaamya Varagur, Helen Xun, Sara Wallam, Alexander Karius, Rafael Ospino, Jenny Ji, Sai Anusha Sanka, John Daines, Rachel Skladman, Oluseyi Aliu, Justin M. Sacks

Research output: Contribution to journalArticlepeer-review


Background  Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. Methods  A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t -tests, Chi-square analysis, and multivariate logistic regression. Results  Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). Conclusion  Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

Original languageEnglish
Pages (from-to)549-558
Number of pages10
JournalJournal of reconstructive microsurgery
Issue number7
StatePublished - Jul 5 2022


  • DIEP reconstruction
  • free flap
  • microsurgery
  • microvascular anastomosis


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