{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T04:50:03Z","timestamp":1785732603944,"version":"3.56.0"},"reference-count":53,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2023,4,16]],"date-time":"2023-04-16T00:00:00Z","timestamp":1681603200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP\/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 \u00b1 1.8 vs. 6.3 \u00b1 1.5 days, p = 0.019; double 8.5 \u00b1 3.8 vs. 6.6 \u00b1 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 \u00b1 78.7 vs. 227.5 \u00b1 54.7 min, p = 0.018; double 448.0 \u00b1 85.6 vs. 341.2 \u00b1 43.1 min, p = 0.008), flap ischemia time (53.6 \u00b1 15.1 vs. 40.9 \u00b1 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon\u2019s skills as well as the overall experience of the medical institution.<\/jats:p>","DOI":"10.3390\/jcm12082894","type":"journal-article","created":{"date-parts":[[2023,4,17]],"date-time":"2023-04-17T02:02:59Z","timestamp":1681696979000},"page":"2894","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study"],"prefix":"10.3390","volume":"12","author":[{"given":"Charalampos","family":"Varnava","sequence":"first","affiliation":[{"name":"Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany"},{"name":"Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp","family":"Wiebringhaus","sequence":"additional","affiliation":[{"name":"Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany"},{"name":"Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"Hirsch","sequence":"additional","affiliation":[{"name":"Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany"},{"name":"Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Dermietzel","sequence":"additional","affiliation":[{"name":"Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany"},{"name":"Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian","family":"Kueckelhaus","sequence":"additional","affiliation":[{"name":"Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany"},{"name":"Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,4,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1016\/0007-1226(89)90075-1","article-title":"Inferior epigastric artery skin flaps without rectus abdominis muscle","volume":"42","author":"Koshima","year":"1989","journal-title":"Br. J. Plast. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1097\/00000637-199401000-00007","article-title":"Deep Inferior Epigastric Perforator Flap for Breast Reconstruction","volume":"32","author":"Allen","year":"1994","journal-title":"Ann. Plast. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1016\/j.bjps.2005.04.061","article-title":"The deep inferior epigastric perforator flap for breast reconstruction, the learning curve explored","volume":"59","author":"Busic","year":"2006","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1097\/01.sap.0000253326.85829.45","article-title":"A Critical Review of Perioperative Complications in 175 Free Deep Inferior Epigastric Perforator Flap Breast Reconstructions","volume":"59","author":"Hofer","year":"2007","journal-title":"Ann. Plast. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1002\/micr.20352","article-title":"Training program and learning curve in experimental microsurgery during the residency in plastic surgery","volume":"27","author":"Lascar","year":"2007","journal-title":"Microsurgery"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1097\/01.PRS.0000110328.47206.50","article-title":"A 10-Year Retrospective Review of 758 DIEP Flaps for Breast Reconstruction","volume":"113","author":"Gill","year":"2004","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1016\/j.bjps.2012.08.024","article-title":"Increments in ischaemia time induces microvascular complications in the DIEP flap for breast reconstruction","volume":"66","author":"Marre","year":"2013","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1548","DOI":"10.1097\/BRS.0b013e318252d44b","article-title":"Learning curve and clinical outcomes of minimally invasive transforaminal lumbar interbody fusion: Our experience in 86 consecutive cases","volume":"37","author":"Lee","year":"2012","journal-title":"Spine"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.1097\/00006534-199311000-00026","article-title":"Assessment of Ischemia-Induced Reperfusion Injury in the Pig Latissimus Dorsi Myocutaneous Flap Model","volume":"92","author":"Morris","year":"1993","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1016\/j.bjps.2012.09.020","article-title":"Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap","volume":"66","author":"Lee","year":"2013","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1097\/00000637-199705000-00010","article-title":"Ischemic Time and Free Flap Success","volume":"38","author":"Kroll","year":"1997","journal-title":"Ann. Plast. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1002\/micr.30203","article-title":"Time-dependent factors in DIEP flap breast reconstruction","volume":"37","author":"LaPorta","year":"2017","journal-title":"Microsurgery"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1112","DOI":"10.1016\/j.bjps.2007.12.090","article-title":"Preoperative CT angiography reduces surgery time in perforator flap reconstruction","volume":"62","author":"Smit","year":"2009","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1148","DOI":"10.1097\/PRS.0b013e31819e23e1","article-title":"Advantages of Preoperative Computed Tomography in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction","volume":"123","author":"Casey","year":"2009","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1016\/j.bjps.2009.01.015","article-title":"Performing two DIEP flaps in a working day: An achievable and reproducible practice","volume":"63","author":"Acosta","year":"2010","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_16","unstructured":"Di Pompeo, F.S., Paolini, G., D\u2019Orsi, G., Atzeni, M., Catalano, C., Cannavale, G., Cilia, F., Firmani, G., and Sorotos, M. (2023). Free-style technique versus computed tomographic angiography\u2014Guided perforator selection in deep inferior epigastric perforator flap harvest: A prospective clinical study. Microsurgery, published online ahead of print."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1016\/j.anplas.2015.02.005","article-title":"The DIEP flap breast reconstruction: Starting from scratch in a university hospital","volume":"60","author":"Bodin","year":"2015","journal-title":"Ann. Chir. Plast. Esthet."},{"key":"ref_18","first-page":"552","article-title":"Breast reconstruction with deep inferior epigastric perforator flaps","volume":"94","author":"Cubitt","year":"2012","journal-title":"Ind. Mark. Manag."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"550e","DOI":"10.1097\/PRS.0b013e318262f14a","article-title":"Tracking the Learning Curve in Microsurgical Skill Acquisition","volume":"130","author":"Selber","year":"2012","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_20","first-page":"1","article-title":"Learning Curve and Clinical Outcome of Biportal Endoscopic-Assisted Lumbar Interbody Fusion","volume":"2020","author":"Kim","year":"2020","journal-title":"BioMed Res. Int."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1227\/01.NEU.0000156470.79032.7B","article-title":"Assessment of the Learning Curve for Lumbar Microendoscopic Discectomy","volume":"56","author":"Nowitzke","year":"2005","journal-title":"Neurosurgery"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"E7","DOI":"10.3171\/2013.5.FOCUS13157","article-title":"Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion","volume":"35","author":"Silva","year":"2013","journal-title":"Neurosurg. Focus"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1016\/j.ijsu.2014.10.028","article-title":"Learning curve for gasless endoscopic thyroidectomy using the trans-axillary approach: CUSUM analysis of a single surgeon\u2019s experience","volume":"12","author":"Kwak","year":"2014","journal-title":"Int. J. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1381\/0960892053268507","article-title":"The Learning Curve Measured by Operating Times for Laparoscopic and Open Gastric Bypass: Roles of Surgeon\u2019s Experience, Institutional Experience, Body Mass Index and Fellowship Training","volume":"15","author":"Ballantyne","year":"2005","journal-title":"Obes. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1007\/s00464-018-6277-y","article-title":"True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation","volume":"33","author":"Kim","year":"2018","journal-title":"Surg. Endosc."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1016\/j.jamcollsurg.2017.01.023","article-title":"Single-Surgeon Learning Curve in 111 Laparoscopic Distal Pancreatectomies: Does Operative Time Tell the Whole Story?","volume":"224","author":"Cipriani","year":"2017","journal-title":"J. Am. Coll. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1111\/hpb.12412","article-title":"The learning curve for robotic distal pancreatectomy: An analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre","volume":"17","author":"Shakir","year":"2015","journal-title":"HPB"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1177\/2192568219880872","article-title":"Minimally Invasive Spine Surgery: The Learning Curve of a Single Surgeon","volume":"10","author":"Kimchi","year":"2019","journal-title":"Glob. Spine J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1446","DOI":"10.1016\/j.ejso.2020.02.020","article-title":"Endoscopic assisted breast conserving surgery for breast cancer: Clinical outcome, learning curve, and patient reported aesthetic results from preliminary 100 procedures","volume":"46","author":"Lai","year":"2020","journal-title":"Eur. J. Surg. Oncol. (EJSO)"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"243","DOI":"10.4143\/crt.2020.063","article-title":"Impact of the Learning Curve on the Survival of Abdominal or Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer","volume":"53","author":"Li","year":"2021","journal-title":"Cancer Res. Treat."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e279","DOI":"10.1016\/j.clbc.2020.09.013","article-title":"Evaluation of the Learning Curve in Robotic Nipple-sparing Mastectomy for Breast Cancer","volume":"21","author":"Loh","year":"2021","journal-title":"Clin. Breast Cancer"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1088","DOI":"10.1302\/0301-620X.99B8.BJJ-2016-1119.R1","article-title":"Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur","volume":"99-B","author":"Klem","year":"2017","journal-title":"Bone Jt. J."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/SAP.0b013e31828d994d","article-title":"Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: Does nulliparity bias flap viability?","volume":"74","author":"Santanelli","year":"2015","journal-title":"Ann. Plast. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1055\/s-0030-1267835","article-title":"A Clinical Review of 9 Years of Free Perforator Flap Breast Reconstructions: An Analysis of 675 Flaps and the Influence of New Techniques on Clinical Practice","volume":"27","author":"Acosta","year":"2010","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1016\/j.bjps.2019.07.022","article-title":"Starting an autologous breast reconstruction program after plastic surgical training. Is it as good as it gets?","volume":"73","author":"Beudeker","year":"2020","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1097\/00006534-200003000-00017","article-title":"Cost-Based Comparison between Perforator Flaps and TRAM Flaps for Breast Reconstruction","volume":"105","author":"Kaplan","year":"2000","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1016\/j.bjps.2008.04.015","article-title":"The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction","volume":"62","author":"Uppal","year":"2009","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2039","DOI":"10.1001\/jamainternmed.2013.9763","article-title":"Health Care\u2013Associated Infections: A meta-analysis of costs and financial impact on the US health care system","volume":"173","author":"Zimlichman","year":"2013","journal-title":"JAMA Intern. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1089\/sur.2017.089","article-title":"Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review","volume":"18","author":"Cheng","year":"2017","journal-title":"Surg. Infect."},{"key":"ref_40","first-page":"1","article-title":"Identification of risk factors by systematic review and development of risk-adjusted models for surgical site infection","volume":"15","author":"Gibbons","year":"2011","journal-title":"Heal. Technol. Assess."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Korol, E., Johnston, K., Waser, N., Sifakis, F., Jafri, H., Lo, M., and Kyaw, M.H. (2013). A Systematic Review of Risk Factors Associated with Surgical Site Infections among Surgical Patients. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0083743"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"3531","DOI":"10.1007\/s00464-011-1753-7","article-title":"Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: A multicenter study","volume":"25","author":"Kurmann","year":"2011","journal-title":"Surg. Endosc."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Yamamoto, S., Nagamine, Y., Miyashita, T., Ito, S., Iwasawa, Y., Kawai, M., Saito, S., Tamai, T., and Goto, T. (2020). Perioperative and anesthetic risk factors of surgical site infection in patients undergoing pancreaticoduodenectomy: A retrospective cohort study. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0240490"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1016\/j.jamcollsurg.2014.12.040","article-title":"How Slow Is Too Slow? Correlation of Operative Time to Complications: An Analysis from the Tennessee Surgical Quality Collaborative","volume":"220","author":"Daley","year":"2015","journal-title":"J. Am. Coll. Surg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"104","DOI":"10.3109\/2000656X.2013.819003","article-title":"Complications and morbidity following breast reconstruction\u2014A review of 16,063 cases from the 2005\u20132010 NSQIP datasets","volume":"48","author":"Fischer","year":"2013","journal-title":"J. Plast. Surg. Hand Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1080\/2000656X.2016.1272462","article-title":"Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction","volume":"51","author":"Thorarinsson","year":"2017","journal-title":"J. Plast. Surg. Hand Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1177\/2292550319880921","article-title":"High-Risk Plastic Surgery: An Analysis of 108,303 Cases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)","volume":"28","author":"Wan","year":"2019","journal-title":"Plast. Surg."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1097\/00000658-199908000-00016","article-title":"Risk Factors for Prolonged Length of Stay After Major Elective Surgery","volume":"230","author":"Collins","year":"1999","journal-title":"Ann. Surg."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1097\/ALN.0b013e3181fc6e0a","article-title":"Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort","volume":"113","author":"Canet","year":"2010","journal-title":"Anesthesiology"},{"key":"ref_50","first-page":"34","article-title":"The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: A retrospective study of 256 consecutive cases","volume":"35","author":"Longo","year":"2014","journal-title":"Microsurgery"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1097\/SAP.0b013e3180698385","article-title":"The Rib-Sparing Technique for Internal Mammary Vessel Exposure in Microsurgical Breast Reconstruction","volume":"60","author":"Parrett","year":"2008","journal-title":"Ann. Plast. Surg."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"674","DOI":"10.1054\/bjps.1999.3240","article-title":"Contour deformity at the internal mammary recipient site","volume":"52","author":"Schwabegger","year":"1999","journal-title":"Br. J. Plast. Surg."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1054\/bjps.1999.3210","article-title":"Problems associated with the use of internal mammary vessels as recipients for free flap breast reconstruction","volume":"52","author":"Kavouni","year":"1999","journal-title":"Br. J. Plast. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/8\/2894\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:16:41Z","timestamp":1760123801000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/8\/2894"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,16]]},"references-count":53,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2023,4]]}},"alternative-id":["jcm12082894"],"URL":"https:\/\/doi.org\/10.3390\/jcm12082894","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,16]]}}}