Determinants and clinical impact of ischemia time in microsurgical breast reconstruction: A multicenter registry analysis of 4209 flaps

von Fritschen U, Keck M, Fertsch S, Gazyakan E, Arkudas A, Schiltz D (2026)

Publication Type: Journal article

Publication year: 2026

Journal

Journal of Plastic Reconstructive and Aesthetic Surgery Elsevier

Book Volume: 121

Pages Range: 122-130

DOI: 10.1016/j.bjps.2026.07.038

Abstract

Background Ischemia time is a key determinant of microsurgical free-flap survival and potentially modifiable risk factor in autologous breast reconstruction. However, factors influencing ischemia time within complex workflows are insufficiently understood. Existing evidence is largely limited to single-center, retrospective studies that focused predominantly on deep inferior epigastric perforator flaps. Methods Prospectively collected data from the German national registry, including 22 centers, for autologous breast reconstruction were analyzed. A subcohort of 4209 unilateral microsurgical breast reconstructions performed in 4113 patients between 2011 and 2018 was evaluated. Generalized linear models were used to assess the effects of flap type, intraoperative repositioning, anastomosis technique, surgeon-related factors, and recipient vessel choice on ischemia time. Associations with operative duration and clinical outcomes were examined using multivariable regression. Results Procedures that required intraoperative repositioning showed significantly longer ischemia times than non-repositioning procedures (mean difference 43 min, p <0.001). Hand-sewn venous anastomoses resulted in significantly longer ischemia times than did coupler-assisted anastomoses, with this difference increasing over time (mean difference 15 min, p =0.003). Prolonged ischemia time was associated with arterial revision and flap loss, whereas operative duration showed the strongest association with venous revision. Conclusion Ischemia time in microsurgical breast reconstruction is strongly influenced by technical and organizational factors. Coupler-assisted anastomoses shortened the ischemia time and appeared to be less influenced by surgeon-related variability and procedural complexity. Prolonged ischemia time continued to be associated after adjustment with arterial complications and flap loss, whereas operative duration showed its strongest and most robust association with venous anastomotic revision, thereby supporting ischemia time as a clinically relevant workflow-dependent quality metric.

Authors with CRIS profile

Andreas Arkudas Department of Plastic and Hand Surgery

Involved external institutions

HELIOS Kliniken DE Germany (DE) Agaplesion Diakonieklinikum Hamburg DE Germany (DE) Sana Kliniken AG DE Germany (DE) Ruprecht-Karls-Universität Heidelberg DE Germany (DE)

How to cite

APA:

von Fritschen, U., Keck, M., Fertsch, S., Gazyakan, E., Arkudas, A., & Schiltz, D. (2026). Determinants and clinical impact of ischemia time in microsurgical breast reconstruction: A multicenter registry analysis of 4209 flaps. Journal of Plastic Reconstructive and Aesthetic Surgery, 121, 122-130. https://doi.org/10.1016/j.bjps.2026.07.038

MLA:

von Fritschen, U., et al. "Determinants and clinical impact of ischemia time in microsurgical breast reconstruction: A multicenter registry analysis of 4209 flaps." Journal of Plastic Reconstructive and Aesthetic Surgery 121 (2026): 122-130.

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