Improving outcomes in microsurgical breast reconstruction: Lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon

Background: Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. Methods: Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative (<six weeks) complications and their management. Results: 406 Consecutive free flap microsurgical breast reconstructions (164 unilateral and 121 bilateral) were performed in 285 patients over the study period. Deep inferior epigastric artery perforator (DIEP) flaps (88%, n = 359) were used most commonly followed by muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps (11%, n = 44), and fascial-sparing TRAM (FS-TRAM) flaps (0.7%, n = 3). One-hundred-seventy-one (48%) DIEP flaps were based on a single perforator while 188 (52%) had multiple perforators. The internal mammary (IM) artery and vein were used as the recipient vessels for 99% (n = 403) of flaps. A second venous anastomosis was required for 11.8 percent (n = 48) of flaps. Partial flap failure occurred in nine (2.2%) flaps while total flap failure occurred in two flaps (0.5%). Minimum follow-up was three months. Conclusions: Incorporating a number of algorithms into our practice has enabled us to simplify the decision-making processes involved in microsurgical breast reconstruction and to consistently obtain successful surgical outcomes.

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