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DIEP flap reconstruction is the gold‑standard autologous option, but perioperative anaemia management remains challenging. Routine dual group‑and‑screen (G&S) testing is widespread, despite low transfusion rates and limited evidence that patients benefit from blanket testing. Identifying practical predictors of blood loss—such as baseline haemoglobin, flap weight, and operative duration—may allow risk‑stratified testing that preserves safety while reducing unnecessary investigations, cost, and patient burden.

A retrospective review was conducted of all DIEP reconstructions performed at a single centre from January 2023–December 2024. Demographic, operative, and treatment‑related variables were collected, including comorbidities, neoadjuvant therapy, radiotherapy, operative time, and flap weight (summed for bilateral cases). Primary outcomes were perioperative red‑cell transfusion and change in haemoglobin (Hb). Linear regression assessed the relationship between flap weight and perioperative Hb drop.

200 patients who underwent DIEP reconstruction were studied. Mean pre‑operative Hb was 129.93 ± 12.63 g/L (Hct 0.384), falling post‑operatively to 107.79 g/L (Hct 0.315), giving a mean Hb drop of 22.13 ± 10.82 g/L and Hct drop of 0.070. Paired values were available for 198 Hb and 196 Hct results. Most patients (92%) had two valid G&S samples; 6% had one, and 2% had none. Only two patients (1%) required transfusion, and the re‑operation (eg; relook, debridement, hematoma evacuation) rate was 7.5%. Mean Hb drop per 100 g flap weight was 2.224 g/L. Each additional 100 g of flap weight was associated with a 0.33 g/L increase in Hb drop (95% CI −0.01–0.67; p = 0.05). Pre‑operative Hb strongly correlated with absolute Hb drop (r = 0.49, p < 0.001), indicating baseline physiology has greater influence on perioperative Hb change than flap weight alone.

Peri-operative transfusion after DIEP reconstruction was rare, suggesting routine pre-operative group and save may be low yield for most patients. Flap weight demonstrated only a modest association with Hb drop. A selective, risk-stratified approach (e.g., baseline anaemia, known antibodies/prior transfusion, bilateral or high anticipated flap weight, significant comorbidity, or other predictors of increased blood loss) could reduce unnecessary testing, cost, and phlebotomy while maintaining patient safety.

Microsurgical thrombosis is a critical complication for free flap surgery. Evidence evaluating the efficacy of intraoperative thromboprophylaxis in mitigating this complication during DIEP flap breast reconstruction remains limited. Here, we report a retrospective analysis of all DIEP flap breast reconstructions performed at our institution over a six-year period.

This single-center analysis offers a retrospective review of all female patients who underwent DIEP flap breast reconstruction from January 2018 to June 2024. Subjects were divided into two groups, a control group and a treatment group with the intraoperative bolus administration of 2000 IU unfractionated heparin (UFH). Patient characteristics, therapeutic variables, intraoperative details and postoperative outcomes were extracted and analyzed. Postoperative complications were classified into subgroups: acute complications (<= 4 days), and delayed complications (> 4 days).

This study included 114 patients (141 breasts), corresponding to 48 patients in the control cohort, and 66 patients in the UFH cohort. No significant differences were observed in the occurrence of complications in intraoperative (p = 0.226), acute (p = 0.839), and delayed settings (p = 1.00). Notably, the risk of thrombosis and hematoma were comparable. Interestingly, ischemia time and total operative duration were significantly prolonged in the control group (p < 0.05).

Intraoperative anticoagulant prophylaxis using UFH did not diminish acute thrombotic complications; however, it was also not associated with an increased risk of hematoma and bleeding. These findings offer valuable insights regarding the clinical relevance and safety profile of perioperative UFH administration.

Autologous breast reconstruction using free tissue transfer, primarily the Deep Inferior Epigastric Perforator (DIEP) flap, is the gold standard for post-mastectomy restoration. Despite high success rates, post-operative haematoma remains a common complication (2-15%) that can jeopardize flap viability via pedicle compression or vasospasm. While Tranexamic Acid (TXA) is a proven anti-fibrinolytic in other specialties, concerns persist regarding its safety in microsurgery due to the theoretical risk of microvascular thrombosis and systemic venous thromboembolism (VTE). This study evaluates the safety and efficacy of TXA in a large microsurgical breast reconstruction cohort.

A retrospective cohort study was conducted on patients undergoing free flap breast reconstruction between January 2022 and December 2024. TXA was typically administered as a 1g single dose at induction. Outcomes measured included flap failure, haematoma incidence, return to theatre (RTT), and transfusion requirements. Statistical analysis utilized logistic regression and Student's t-tests, with multivariate models adjusted for age, BMI, smoking status, concurrent axillary surgery and recent neoadjuvant chemotherapy or prior radiotherapy.

A total of 370 flaps were performed in 318 patients, with TXA administered in 256 patients (69.2%). Complete flap failure occurred in only 1% of cases (n=4). Logistic regression showed no association between TXA administration and flap failure (OR 0.21, p=0.1). Post-operative haematoma occurred in 6.6% of patients (n=21). Crucially, TXA administration was significantly associated with a reduction in RTT for haematoma (OR 0.21, p=0.01). While TXA patients had a statistically smaller drop in haemoglobin (3g/L, p=0.008), there was no significant reduction in transfusion requirements (OR 0.95, p=0.9). No VTE events were recorded in the cohort.

TXA appears safe for use in microsurgical breast reconstruction, and is associated with a reduced return to theatre rate for intervention in the context of haematoma. This is without increasing the risk of flap failure or thromboembolic events. These findings support the routine inclusion of TXA in multimodal protocols to minimize perioperative morbidity in free tissue transfer.

Continuous tissue oximetry has been proposed as an adjunctive monitoring tool in free flap surgery. Its potential benefit may be particularly relevant in buried flaps, where direct clinical assessment is limited. In addition to safety aspects, its potential impact on monitoring workflow and resource utilisation is of increasing interest.

We performed a monocentric retrospective review of consecutive autologous breast reconstructions monitored postoperatively with continuous tissue oximetry (T-Stat). Both buried and skin-island flaps were included.

We analysed 31 autologous breast reconstructions, comprising 16 buried and 15 skin-island flaps, including 26 deep inferior epigastric perforator (DIEP), 3 transverse myocutaneous gracilis (TMG), and 2 superior gluteal artery perforator (SGAP) flaps. Re-exploration was required in three flaps, all in buried reconstructions. In two cases, clinical findings already indicated vascular compromise, whereas in one case tissue oximetry showed abnormal values before clinical signs became evident. All revised flaps were successfully salvaged, and no total flap losses occurred. Continuous tissue oximetry generated three false-positive alerts in clinically stable flaps, most frequently during early mobilisation due to probe displacement or motion artefact. Two buried flaps developed minor superficial pressure necrosis at the probe site, resolving with conservative treatment. Minor transient (~1 mm) pigmentation marks were observed in skin-island flaps without clinical consequence.

In our experience with 31 autologous breast reconstructions, continuous tissue oximetry was feasible in both buried and skin-island flaps. Monitoring showed variable concordance with clinical assessment, with occasional earlier detection of vascular compromise but also false-positive alerts and minor probe-related complications. Continuous tissue oximetry is particularly valuable in buried flaps, where clinical assessment is limited. When integrated with remote monitoring, continuous tissue oximetry may allow real-time surveillance without repeated bedside visits, potentially reducing staff workload and facilitating earlier intervention. Prospective cost-effectiveness studies are planned to further substantiate its clinical and economic value.

Breast reconstruction is a vital part of multidisciplinary breast cancer care, with microsurgical techniques, especially DIEP flap surgery, providing long-lasting improvement of quality of life by reconstructing form and function. Given the complexity of these microsurgical procedures, the management of perioperative complications is crucial, as it significantly influences treatment success. Early recognition and anticipation of potential complications are therefore essential for a successful clinical outcome and to ensure patient safety.

In this retrospective study, approximately 450 patients who underwent autologous breast reconstruction between 2014 and 2024 at the practice XX, Y, a center certified by the XY Society of Plastic, Reconstructive and Aesthetic Surgery, were analyzed.
Patient- and surgery-specific factors, including demographic and health characteristics, oncological treatments, and reconstructive details, were recorded. Complications were classified by site (flap vs. donor) and timing (early vs. late), encompassing vascular, tissue, as well as wound-healing-related events. Revision procedures were recorded separately for both flap-related and donor-site-related complications and differentiated into emergency or secondary corrective surgery.

Due to the large number of cases and parameters analyzed, this study provides insights into the occurrence of perioperative complications and their clinical relevance.

The results support a targeted assessment of each patient’s individual risk, thereby contributing to further improvements in care for patients undergoing microsurgical breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is considered the gold standard for autologous breast reconstruction. Many patients have had previous abdominal surgery (PAS), which poses a challenge in flap harvesting and may impact both abdominal vascularity and structural integrity. This study aimed to clarify the impact of PAS on DIEP flap complications.

A monocentric retrospective analysis of patients undergoing DIEP flap breast reconstruction from February 2018 to May 2024 was conducted. Preoperative characteristics, operative notes, and postoperative complications were collected and analyzed.

A total of 114 patients, representing 141 DIEP flap breast reconstructions, were included. The study group comprised 58 patients with PAS, whereas the control group included 56 patients without PAS. We observed no significant differences in overall flap or recipient-site (P = 0.365) and abdominal donor-site (P = 0.617) complication rates. A significant increase in overall complication risk was associated with an increase in body mass index (P = 0.041), immediate reconstruction (P = 0.038), and midline laparotomy (P = 0.049) in univariate correlation analysis, and a decrease in flap and recipient-site complications in patients who had a cesarean section (P = 0.035) in multivariate analysis.

PAS was not associated with increased complication rates at the flap and recipient-site or abdominal donor site after DIEP flap breast reconstruction. Interestingly, our findings suggest that patients with a history of cesarean section had fewer flap and recipient-site complications.

Autologous breast reconstruction using free flaps remains a standard option for oncologic patients, including those after radiotherapy. Tissue changes from previous treatment can compromise reconstructive outcomes, making reliable surgical techniques essential. We report our five-year experience with buried DIEP and TMG flap reconstruction.

A total of 44 patients (mean age 53 years) underwent breast reconstruction using buried DIEP (40) or TMG (4) flaps between 2021 and 2025. In all cases, flaps were completely deepithelialized and buried beneath the native breast skin. Postoperative monitoring followed a standardized protocol based on Doppler assessment of arterial and venous signals with clinical evaluation of edema and skin discoloration. The first team-based check, performed 60 minutes after surgery, included Doppler and flap volume evaluation, with swelling considered an early sign of venous congestion. Subsequent monitoring was performed by a dedicated team of specially trained nurses. Data were retrospectively analyzed for complications, timing after radiotherapy, and hospital stay. Major complications required surgical revision, all performed by the primary operating surgeon. Minor complications were managed conservatively.

Fifteen patients had prior radiotherapy, with reconstruction performed at least 6 months after treatment. Mean hospital stay was 7.7 days. No cases of flap loss were observed, yielding 100% flap survival. Four patients (9%) required re-exploration due to signs of impaired perfusion. Revision of the venous anastomosis was necessary only in one case (2%), as indicated by the absence of a Doppler signal. Minor complications were limited to fat necrosis in 7 patients and one case of delayed wound healing. Secondary corrective procedures were performed in 9 patients, most commonly lipofilling.

Buried DIEP and TMG flap reconstruction is a safe and reliable technique for autologous breast reconstruction, even in patients after radiotherapy. High flap survival and low major complication rates are achieved through careful patient selection, a standardized Doppler-based monitoring protocol including arterial and venous signal control, structured postoperative handover, and management by a dedicated, specially trained nursing team. Secondary procedures may be required but do not compromise overall reconstructive success.

The superficial inferior epigastric artery (SIEA) flap avoids violation of the abdominal muscular wall; however, it has historically been considered unreliable due to vascular variability and a perceived higher failure rate compared with the deep inferior epigastric perforator (DIEP) flap. The precise factors contributing to this reputation have not been fully clarified, and standardized strategies to improve reliability remain limited.

Since 2022, the SIEA flap has been employed as the primary option in 100% of abdominal-based breast reconstructions, without conversion to DIEP. A consecutive series of 27 patients (32 flaps, including 5 bilateral reconstructions) is presented. Technical refinements, intraoperative decision-making, vascular management, and perioperative protocols aimed at optimizing flap perfusion and minimizing complications were analyzed.

A total of 32 SIEA flaps were performed, with one total flap loss. No intraoperative conversions to DIEP were required. Critical factors associated with successful outcomes included meticulous arterial handling, careful evaluation of vessel caliber and flow, strategic venous outflow optimization (including selection and number of recipient veins), and systematic use of antithrombotic and vasodilatory protocols.

When performed within a structured and technically optimized framework, the SIEA flap may achieve consistent and reproducible outcomes, and its role may extend beyond traditionally accepted indications. Further data are required to clarify its reliability and appropriate indications.

Autologous breast reconstruction represents a particular surgical challenge, especially in slender patients. Perforator-based PAP flaps harvested from the thigh provide a reliable and well-established alternative reconstructive option in this patient population.

A review of the double PAP flap in breast reconstruction was conducted, with particular emphasis on flap durability, complication rates, oncologic recurrence, and technical feasibility, and was compared with alternative reconstructive options in the context of a comprehensive review of the literature.

The DIEP flap remains the standard technique for autologous breast reconstruction in most cases. However, the double PAP flap offers several relevant advantages and represents a valuable alternative, particularly in slender patients or in those with a previously operated abdomen. Patient repositioning is not required. As the flap is muscle-sparing, it provides stable volume, a soft consistency, and excellent moldability. Donor-site morbidity is low, and the vascular pedicle is of adequate length.

Excellent aesthetic outcomes can be achieved using the kissing technique or by employing the PAP flap as a stacked flap. The combination of flaps as a buried flap is particularly suitable in skin-sparing mastectomy, as the slightly darker pigmentation of the tissue is not visible.

To introduce and clinically evaluate the effectiveness of a novel surgical technique—“Folded Flap”—designed for comprehensive reduction of nipple height, diameter, and base width while maintaining a natural cylindrical shape and preserving nipple sensitivity and lactation potential.

A total of 61 patients with varying degrees of nipple hypertrophy underwent nipple reduction using the author’s technique. The method involves anatomically guided wedge resection based on preoperative arc-shaped marking and the placement of a three-point key suture, which creates a folded flap and allows for natural reshaping of the nipple without compromising vascular supply.

Mean reduction in nipple height and diameter ranged from 40% to 70%. All patients reported high satisfaction with the aesthetic outcome. No cases of necrosis, nipple deformity, sensory loss, or lactation issues were observed.

The “Folded Flap” technique offers a simple, safe, and reproducible approach to nipple hypertrophy correction. It allows for controlled multi-dimensional reduction with consistent aesthetic outcomes and minimal surgical trauma, making it a valuable tool in modern aesthetic breast surgery.