# 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.

## Key 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.