Single vs. Multiple Perforator Flaps in Autologous Breast Reconstruction: A Regression Analysis of Clinical Outcomes and Financial Metrics.

[BACKGROUND] Perforator selection in free flap breast reconstruction is complex, often involving both pre-operative imaging and clinical examination. The number of perforators selected for flap design has classically been analyzed as a trade-off between donor site morbidity, flap perfusion, and operative time.

[METHODS] Retrospective review of 258 consecutive abdominal autologous breast reconstruction patients, stratified by laterality and single versus multiple perforator flaps. Primary outcomes were operating time, length of stay, daily/total opioid use, flap loss, fat necrosis, and hernia/bulge. Financial metrics analyzed included charges, total cost, and estimated margin.

[RESULTS] While controlling for bilateral and unilateral reconstruction, each additional perforator added an average of 27.6 minutes of OR time (p>0.001), 0.22 days length of stay (p=0.011), and 16.2 morphine milligram equivalents (MME) of total opioid use (p=0.021). The likelihood of flap thrombosis, flap loss, fat necrosis, or hernia/bulge was similar between single and multiple perforator cohorts. Each additional perforator added $4,591 in charges (p=0.033), $1,425 in total cost (p=0.013), and decreased estimated margin by $2,717 (p=0.010).

[CONCLUSION] These results demonstrate equivalent donor and recipient site clinical outcomes between single vs. multiple perforator flaps. This likely reflects the surgeons' approach to balanced flap designs that prioritize adequate flap perfusion while attempting to limit excess abdominal dissection. When multiple perforators are indicated, OR time, length of stay, and MME use increase accordingly. The financial impact of this is not insignificant and warrants consideration.