Background
• DIEP flap remains the most reliable microvascular breast reconstruction free flap, with significant lower revision rates.
• Multiple studies have found that compromise happens in the first 24 to 48 hours post op.
• Shorter monitoring duration would ultimately lead to shorter inpatient hospital stay.
• ERAS protocols have been associated with significantly lower opioid requirements, less antiemetic use, less pain in the recovery room, earlier return to normal diet, and significant cost savings.

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Objectives
• We sought to analyze the trends in patient LOS undergoing DIEP reconstruction at a high-volume microsurgery center single institution prior to and following implementation of a novel ERAS protocol.
• we propose a standardized ERAS protocol for DIEP flap patients which may serve as a guide for institutions that have yet to define their own post-operative protocols.

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Methods
• Retrospective single-institution cohort study of patients undergoing unilateral or bilateral DIEP breast reconstruction (immediate and delayed) from 2017–2025.
• Outcomes before and after ERAS implementation (July 2020) were compared.
• Demographics, length of stay (LOS), and complications were analyzed.
• Unadjusted comparisons used t-tests, and multivariable linear regression with robust standard errors assessed the association between ERAS implementation and LOS, adjusting for relevant clinical covariates.

Results
• A total of 358 patients underwent DIEP reconstruction.
• Following ERAS implementation, LOS decreased by 1.02 days (p<0.001). Mean LOS improved from 4.17 days in 2017 to 2.6 days in 2025.
• In 2025, 75% of patients were discharged within ≤3 days, compared to 75% requiring ≥4 days in 2017.
• Two flap failures were observed.

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Discussion
• Initiating a preoperative schedule of analgesics allows for adequate baseline pain control in the patient.
• Patient expectations are a fundamental aspect of an earlier discharge date. Patients should be reassured at their initial visit that early discharge as early as POD 2 is feasible and safe.
• Post-ERAS implementation was associated with reduced opioid use, including elimination of PCA pumps, likely related to incorporation of TAP blocks.

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Conclusion
• Implementation of ERAS protocol for DIEP free-flap breast reconstruction has reduced LOS when compared with contemporary literature.
• This protocol can be adopted in microsurgical DIEP breast reconstruction to achieve shorter LOS without jeopardizing patient outcomes.

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References

1. van Mulken et al. Plast Reconstr Surg 2022
2. Temple-Oberle et al. The Breast 2021