title: Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon.
abstract: 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.
authors: Department of Plastic and Reconstructive Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
authors: Tim H C
authors: TH
authors: Damen
authors: Andrew N
authors: AN
authors: Morritt
authors: Toni
authors: T
authors: Zhong
authors: Jamil
authors: J
authors: Ahmad
authors: Stefan O P
authors: SO
authors: Hofer
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001943:Breast Neoplasms / Q000601:surgery*; D003661:Decision Support Techniques; D019074:Epigastric Arteries; D005260:Female; D058752:Free Tissue Flaps / Q000009:adverse effects / Q000098:blood supply*; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D061525:Perforator Flap / Q000009:adverse effects / Q000098:blood supply*; D017568:Rectus Abdominis / Q000637:transplantation; D055815:Young Adult
keywords: Algorithm; Breast reconstruction; Complication; DIEP; Free flap; Microsurgery; TRAM