Overlapping Surgery in Plastic Surgery

An Analysis of Patient Safety and Clinical Outcomes

Rajiv P. Parikh, M.D., M.P.H.S.; Ketan Sharma, M.D., M.P.H.; Melissa Thornton, B.S.; Gabriella Brown, B.S.; Terence M. Myckatyn, M.D.


Plast Reconstr Surg. 2019;143(6):1787-1796. 

In This Article

Abstract and Introduction


Background: Overlapping surgery is an important and controversial health care issue. To date, there is minimal evidence on the safety of overlapping surgery in plastic surgery. The purpose of this study was to evaluate and compare outcomes for patients undergoing overlapping surgery versus nonoverlapping surgery in plastic surgery.

Methods: This is a retrospective cohort study of consecutive patients undergoing plastic surgery procedures at a tertiary academic center between January of 2016 and January of 2018. Demographic and procedural characteristics, clinical outcomes, and adverse events were analyzed for patients undergoing overlapping versus nonoverlapping surgery. An a priori power analysis was performed, and chi-square, Wilcoxon rank sum, and bivariate logistic regression tests were used for analyses.

Results: Eight hundred sixty-six patients constituted the study population: 555 (64.1 percent) underwent nonoverlapping surgery and 311 (35.9 percent) underwent overlapping surgery. There was no significant difference (p > 0.050) in mean age, body mass index, tobacco use, American Society of Anesthesiologists rating, or Charlson Comorbidity Index score between cohorts. Comparison of nonoverlapping and overlapping cases revealed no differences in complications (12.1 percent versus 11.9 percent; p = 0.939), reoperations (6.1 percent versus 6.8 percent; p = 0.717), readmissions (3.6 percent versus 3.5 percent; p = 0.960), or emergency room visits (4.7 percent versus 4.8 percent; p = 0.927). Stratification by procedure demonstrated no difference (p > 0.050) in complications between cohorts. Median operative time was significantly longer for overlapping operations (105 minutes versus 83 minutes; p = 0.004).

Conclusions: This study supports the safety of overlapping surgery in plastic surgery.

Clinical Question/Level of Evidence: Therapeutic, III.


The practice of overlapping and concurrent surgery is a controversial and frequently debated issue in contemporary surgical care. Simply considered, overlapping surgery occurs when the same surgeon is responsible for two cases in which any noncritical portion of one operation coincides with any noncritical portion of another operation. In contrast, if the parts of two cases that coincide are critical aspects of the procedure, this is considered concurrent surgery. Although concurrent surgery is rarely practiced, in part because of restrictions on payment set by the Centers for Medicare and Medicaid Services Physician Fee Schedule, overlapping surgery is considered a standard practice in most large tertiary care hospitals.[1] The purported benefits of overlapping surgery include improved workflow efficiency, greater access to care, and improved training opportunities.[2] However, the practice of overlapping surgery has been subject to considerable negative publicity and scrutiny following an investigative article, "Clash in the Name of Care," published in October of 2015 by the The Boston Globe, that outlined instances of complications associated with overlapping and concurrent operations.[3] The media attention generated from this news report prompted a reevaluation of best practice recommendations.[2]

In 2016, the U.S. Senate Finance Committee issued a report highlighting patient safety concerns and calling for additional data and guidance on the practice of overlapping surgery.[4] In an effort to provide guidance, the American College of Surgeons released a revised Statements on Principles in April of 2016 with recommendations for overlapping and concurrent operations.[5] Similarly, the American Society of Plastic Surgeons convened a task force and subsequently released a new policy statement on overlapping and concurrent surgery in March of 2017.[6] Unfortunately, these reports found a lack of data regarding the impact of overlapping surgery on surgical outcomes and patient safety, making it difficult to provide evidence-based policy recommendations. This led to a widespread call for evidence on the safety and outcomes of overlapping surgery.[2,7] It is integral that policy follows evidence, especially when considered in the context of prior governmental regulations in plastic surgery that were made with inadequate data and resulted in adverse consequences (e.g., the regulatory ban on silicone breast implants from 1992 to 2006 following anecdotal media reports on safety concerns that subsequent studies disproved).[8]

To date, few studies have evaluated the safety and clinical outcomes of overlapping surgery compared with nonoverlapping surgery.[9] The paucity of data available for plastic surgery operations precludes patients, physicians, hospital administrators, and policymakers from making evidence-based, informed decisions regarding the practice of overlapping surgery, a timely and important health care issue. Therefore, the purpose of this study was to evaluate and compare the safety profile and clinical outcomes for patients undergoing overlapping surgical procedures versus nonoverlapping surgical procedures in plastic surgery.