Optimising the unilateral DIEP flap breast reconstruction: A United Kingdom-Netherlands multi-centre comparative study

TL;DR

This study compares surgical techniques and outcomes for breast reconstruction in the UK and Netherlands, showing how different methods affect efficiency and complications.

Contribution

The study identifies how surgical models and pathways influence outcomes in DIEP flap breast reconstruction across two countries.

Findings

The UK model had shorter hospital stays but longer surgeries compared to the Netherlands model.

ERAS protocols in the UK were linked to early minor complications, while lean optimization in the Netherlands reduced late re-operations.

Flap survival rates were similar between the two countries despite differing surgical approaches.

Abstract

The deep inferior epigastric perforator (DIEP) flap represents the gold standard in autologous breast reconstruction; however, it is restricted by prolonged operative duration and substantial demands on inpatient capacity. We compared postoperative outcomes across international centres with differing surgical models and perioperative pathways.

A retrospective, two-centre cohort study was undertaken of unilateral DIEP flap reconstructions performed in the United Kingdom (UK) and the Netherlands (NL). The UK cohort (2018–2022) utilised a single-surgeon model with an enhanced recovery after surgery (ERAS) pathway, whereas the NL cohort (2013–2019) employed a co-surgeon model and lean optimisation without ERAS protocols. Patient demographics, operative characteristics, and postoperative complications were compared. Outcomes were analysed by complication severity (Clavien–Dindo), timing (<30 vs. ≥30 days), and potential predictors.

The cohort included 203 patients (203 flaps): 103 from the UK and 100 from NL. Immediate reconstruction predominated in the UK (70% vs. 1%, P < 0.001). Mean operative times were longer in the UK (464 vs. 330 min, P < 0.001), yet length of stay was shorter (4.8 vs. 5.9 days, P < 0.001). Overall complication rates were comparable (61% UK vs. 56% NL). Prolonged operative time predicted early minor complications in the UK cohort and was associated with late minor complications in UK-NL combined analyses. Increased BMI, chemotherapy, radiotherapy, and immediate reconstruction variably predicted fat necrosis and minor complications, while prior abdominal surgery was associated with late re-operation in NL. Flap loss rates (4–7%) were equivalent.

The present study demonstrates that operative workflow, case-mix, and perioperative pathways may influence efficiency and complication profiles without altering flap survival. Pragmatic improvements include ERAS implementation, co-surgeon operating, lean optimisation, and tailored planning for higher-risk patients.