Optimising the unilateral DIEP flap breast reconstruction: A United Kingdom-Netherlands multi-centre comparative study

Background: The deep inferior epigastric perforator (DIEP) flap represents the gold standard in autologous breast reconstruction; however, it is restricted by prolonged operative duration and substantial demands on inpatient capacity. We compared postoperative outcomes across international centres with differing surgical models and perioperative pathways. Methods: A retrospective, two-centre cohort study was undertaken of unilateral DIEP flap reconstructions performed in the United Kingdom (UK) and the Netherlands (NL). The UK cohort (2018-2022) utilised a single-surgeon model with an enhanced recovery after surgery (ERAS) pathway, whereas the NL cohort (2013-2019) employed a co-surgeon model and lean optimisation without ERAS protocols. Patient demographics, operative characteristics, and postoperative complications were compared. Outcomes were analysed by complication severity (Clavien-Dindo), timing (