Comparison of Surgical Time in TDAP Free Flap Procedures: Right vs. Left Donor Site

Abstract

Background

Although free flap reconstruction is well established, the influence of donor site laterality on operative efficiency has not been thoroughly explored. This study evaluated the effect of flap laterality (right vs. left) on operative time in thoracodorsal artery perforator (TDAP) free flap surgery, with a focus on ergonomic implications for right-handed surgeons.

Methods

A retrospective review was conducted on patients who underwent TDAP free flap reconstruction at a single center. Operative times were compared between left- and right-sided flaps. Clinical variables, flap dimensions, and donor site closure techniques were analyzed. Multivariate regression was performed to assess the independent effect of laterality on operative duration, adjusting for confounders.

Results

Left-sided TDAP flaps were associated with significantly longer operative times compared to right-sided flaps (p < 0.01). These cases also involved larger flap dimensions and more frequent use of skin grafts for donor site closure. Multivariate analysis confirmed that left-sided laterality independently predicted increased operative time. All procedures were performed by right-handed surgeons, suggesting that ergonomic factors are a key contributor to these differences. Technical recommendations were proposed to improve efficiency during left-sided harvests.

Conclusion

Donor site laterality significantly affects operative time in TDAP free flap reconstruction, likely due to ergonomic disadvantages for right-handed surgeons. Surgeons should consider laterality during preoperative planning and prioritize right-sided flaps when feasible. Incorporating ergonomic strategies into training and technique may enhance surgical efficiency and outcomes.

Keywords

surgical flap - perforator flap - lower extremity - time factors - surgical anastomosis

Ethical Approval

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of Hanyang University Hospital (IRB No. 2025-01-008).

^‡ Yoo Seok Ha and Suk Young Jung contributed equally to this work.

Publikationsverlauf

Eingereicht: 20. August 2025

Angenommen: 13. Januar 2026

Accepted Manuscript online:
13. Februar 2026

Artikel online veröffentlicht:
25. Februar 2026

• References

• 1 Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free flap monitoring, salvage, and failure timing: a systematic review. J Reconstr Microsurg 2021; 37 (03) 300-308
• 2 Jacobson A, Cohen O. Review of flap monitoring technology in 2020. Facial Plast Surg 2020; 36 (06) 722-726
• 3 Ha Y, Park SO, Park JA, Kim SY, Shim H-S, Kim YH. Analysis of operation duration in thoracodorsal artery perforator free-flap surgery of the lower extremities. Ann Plast Surg 2024; 92 (04) 405-411
• 4 Reiman A, Kaivo-oja J, Parviainen E, Takala E-P, Lauraeus T. Human factors and ergonomics in manufacturing in the industry 4.0 context—a scoping review. Technol Soc 2021; 65: 101572
• 5 Broberg O. Integrating ergonomics into engineering: empirical evidence and implications for the ergonomists. Hum Factors Ergon Manuf Serv Ind 2007; 17 (04) 353-366
• 6 Waters TR. Introduction to ergonomics for healthcare workers. Rehabil Nurs 2010; 35 (05) 185-191
• 7 Catanzarite T, Tan-Kim J, Whitcomb EL, Menefee S. Ergonomics in surgery: a review. Female Pelvic Med Reconstr Surg 2018; 24 (01) 1-12
• 8 Larsson M, Schepman A, Rodway P. Why are most humans right-handed? The modified fighting hypothesis. Symmetry (Basel) 2023; 15 (04) 940
• 9 Llaurens V, Raymond M, Faurie C. Why are some people left-handed? An evolutionary perspective. Philos Trans R Soc Lond B Biol Sci 2009; 364 (1519): 881-894
• 10 Kushner HI. Why are there (almost) no left-handers in China?. Endeavour 2013; 37 (02) 71-81
• 11 Kuo Y-R, Seng-Feng J, Kuo FM, Liu Y-T, Lai P-W. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 2002; 48 (02) 161-166
• 12 Koshima I, Nanba Y, Tsutsui T. et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004; 113 (01) 233-240
• 13 Healy C, Allen Sr RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 2014; 30 (02) 121-125
• 14 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg 2003; 51 (01) 23-29
• 15 Illg C, Heinzel JC, Denzinger M, Schäfer RC, Daigeler A, Krauss S. Mapping of thoracodorsal artery perforators: accuracy of thermography and handheld doppler. J Reconstr Microsurg 2024; 40 (07) 551-558
• 16 Taylor KJ, Davies ROHL, Wheble GAC, Mikhail MM. Donor sites for radial forearm flaps: a direct comparison of closure with a local “hatchet” flap and split thickness skin grafts in a single patient. Br J Oral Maxillofac Surg 2018; 56 (10) 988-989
• 17 Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975; 56 (03) 243-253
• 18 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
• 19 Yu JW, Rifkin WJ, Lee Z-H. et al. Does laterality of lower extremity donor site affect outcomes in microvascular soft tissue lower extremity reconstruction?. J Reconstr Microsurg 2020; 36 (04) 289-293
• 20 Zulbaran-Rojas A, Rouzi MD, Zahiri M. et al. Objective assessment of postural ergonomics in neurosurgery: integrating wearable technology in the operating room. J Neurosurg Spine 2024; 41 (01) 135-145
• 21 Gillespie AM, Wang C, Movassaghi M. Ergonomic considerations in urologic surgery. Curr Urol Rep 2023; 24 (03) 143-155
• 22 Haffar A, Khan IA, Ong C. et al. Stress and strain during total joint arthroplasty are not impacted by hand dominance or operative laterality in orthopedic surgeons. J Arthroplasty 2022; 37 (06) 1054-1058
• 23 Graboyes EM, Hornig JD. Evolution of the anterolateral thigh free flap. Curr Opin Otolaryngol Head Neck Surg 2017; 25 (05) 416-421
• 24 Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg 2006; 59 (06) 571-579
• 25 Lee K-T, Park BY, Kim E-J. et al. Superthin SCIP flap for reconstruction of subungual melanoma: aesthetic functional surgery. Plast Reconstr Surg 2017; 140 (06) 1278-1289
• 26 Illg C, Rachunek-Medved K, Lauer H, Thiel JT, Daigeler A, Krauss S. Thoracodorsal artery perforator diameter and flow velocity correlate with muscle thickness. J Reconstr Microsurg 2026; 42 (01) 30-37