title: The Deep Inferior Epigastric Perforator Learning Curve in the Current Era.
abstract: BACKGROUND
  Over the last 2 decades, the deep inferior epigastric perforator (DIEP) flap has gained significant popularity in breast reconstruction. However, for some, the increased technical difficulties associated with DIEP breast reconstruction can be a discouraging factor in adopting this technique. There has been a trend in the literature to acknowledge an acute learning curve in the adoption of DIEP breast reconstruction but little evidence to support its ongoing relevance to surgeons who gain significant exposure in training.
  
  
  METHODS
  We test the learning curve concept on the senior author's series of 214 DIEP and superficial inferior epigastric artery flaps in a single-surgeon, retrospective study analyzing chronological trends in complication rates both major (total and partial flap loss, reexploration) and minor (fat necrosis, donor site hernia and bulge).
  
  
  RESULTS
  The total complication rate was 7.9%, including 1 (0.5%) partial and 1 (0.5%) total flap failure. A comparison of complication rates in the initial 30 flaps in comparison to the remainder of the series revealed no significant difference in major complications (3.3% vs 3.3%, P = 1.00) or minor complications (6.7% vs 4.3%, P = 0.635). Linear-by-linear analysis performed on chronologically ordered groups of 30 flaps revealed no statistically significant trends over the series.
  
  
  CONCLUSIONS
  The learning curve associated with the DIEP is complex and likely relates to competency gained in both technical and decision-making aspects of breast reconstruction. This series has demonstrated that with adequate training and an algorithmic approach to DIEP breast reconstruction, eliminating the early learning curve and improving early outcomes are possible.
authors.affiliation: From the *Department of Plastic and Reconstructive Surgery, Western Health Melbourne; and †Department of Plastic and Reconstructive Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
authors.forename: Damien G
authors.initials: DG
authors.lastname: Grinsell
authors.forename: Gavin W
authors.initials: GW
authors.lastname: McCoubrey
authors.forename: James P
authors.initials: JP
authors.lastname: Finkemeyer
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery; D016208:Databases, Factual; D019074:Epigastric Arteries / Q000601:surgery / Q000637:transplantation*; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D059032:Learning Curve; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D064827:Myocutaneous Flap / Q000098:blood supply* / Q000637:transplantation; D061525:Perforator Flap / Q000098:blood supply / Q000637:transplantation*; D017568:Rectus Abdominis / Q000098:blood supply / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome