AAPS Main SiteThe Impact of Operative Time on Complications After Plastic Surgery: A Multivariate Regression Analysis of 1,753 Cases
Krista Hardy, BS, Kathryn Davis, PhD, Ryan Constantine, BS, Mo Chen, PhD, James Jewell, MD, Karunakar Dirisala, MS, Jerzy Lysikowski, PhD, Gary Reed, MD, Jeffrey Kenkel, MD.
UT Southwestern Medical Center, Dallas, TX, USA.
PURPOSE: Although convention suggests that longer operative times lead to greater morbidity, there is little evidence within the plastic surgery literature to support this precept. The authors investigate duration of surgery as a determinant of morbidity, with the goal of defining a clinically relevant time after which there is an increased risk of developing complications.
METHODS: A retrospective review was conducted on a broad range of complex plastic surgical procedures (n = 1,801) at UT Southwestern Medical Center from January 1st, 2008 to January 31st, 2012. Adjusting for possible confounders, including baseline patient characteristics and comorbidities, multivariate logistic regression was performed to assess surgery duration as an independent predictor of morbidity. Complications evaluated included infection, dehiscence, erythema, necrosis, seroma, hematoma, delayed wound healing, flap failure, and VTE. To define a cutoff for increased risk, surgeries were grouped by duration and incidence of overall complications was compared among each quintile. Once a cutoff was identified, the cases with operative times above the cutoff were compared to those below it. First, incidences of each type of complication for all operations were independently assessed. To control for procedural complexity, cases were then stratified by type of surgery and overall morbidity was compared.
RESULTS: A total of 1,753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Compared to the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (OR, 1.6; p = 0.017), with progressively greater odds increases of 3.1
times after 4.5 hours (p <0.0001) and 4.7 times after 6.8 hours (p <0.0001) (Figure 1). Surgeries longer than 3 hours were associated with higher rates of wound infection (OR, 2.18; p <0.0001), dehiscence (OR, 4.09; p <0.0001), erythema (OR, 1.76; p = 0.0084), necrosis (OR, 2.88; p <0.001), seroma (OR, 2.20; p <0.001), hematoma (OR, 4.38; p <0.001), and delayed wound healing (OR, 3.00; p = 0.0013). Incidence of VTE approached, but did not reach significance (OR, 2.33; p = 0.055). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. Prolonged surgeries were associated with more post-operative complications for lipectomy (OR, 2.46; p <0.001), pedicle flap (OR, 1.60; p = 0.023), autologous breast reconstruction (OR, 2.01; p = 0.022), tissue expander breast reconstruction (OR, 2.96; p = 0.014), and other breast surgery (OR, 3.05; p = 0.0077). Longer free flaps and rhytidectomies were not significantly different, perhaps due to the small number of patients in these groups (n = 69 and n = 35, respectively).
CONCLUSIONS: Surgery duration is a predictor of complications, with 3 hours being the critical time after which there is a significantly increased risk. Although procedural complexity undoubtedly influences morbidity, operative time independently affects outcomes and should be one of many considerations in surgical decision-making. 
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