The first 150 consecutive DIEP free flaps: Lessons learnt and a guide to efficiency for the junior plastic surgeon

The deep inferior epigastric artery perforator (DIEP) free flap is the gold-standard for breast reconstruction but is technically demanding, resource intensive and time-consuming, making it a daunting task for the junior surgeon.

To report the lessons learnt from the experience of a single surgeon performing their first 150 DIEP reconstructions as a guide for junior surgeons.

Data regarding patient demographics and surgical outcomes from April 2021 to October 2022 were collected retrospectively from medical records. Surgical outcomes were analysed using Microsoft Excel.

Over 17 months, 150 flaps were completed in 97 patients by the senior author (BS). Operative duration was negatively correlated with case number for unilateral DIEPs (r = -0.73, p < 0.05) and for bilateral DIEPs (r = -0.67, p = 0.14). Raise time and ischaemic time were also negatively correlated with case number (r = -0.82, p < 0.05 and r = -0.79, p < 0.05, respectively). There were 10 complications and no flap losses.

The data demonstrate an expected improvement in surgical efficiency with increased experience. We describe the key factors contributing to efficiency in our series, such as preoperative CT angiography, surgical markings prior to the day of surgery, a two-team approach with three diathermy sets, flap raise using monopolar diathermy, preference towards choosing a single dominant perforator and early commitment to perforator choice. This case series acts as a guide for the junior plastic surgeon in achieving safe, aesthetic and efficient results when completing free DIEP flap breast reconstructions.