This study showed that since ADM introduction to our centre, more breast reconstructions have been of the implant-only type with consequent reductions in the more complex and expensive autologous techniques. Implant-only procedures that incorporated ADM use had similar complication rates to those that did not.

Background: The use of CT angiography (CTA) or venous couplers (VCs) has led to shorter operative times in free flap breast reconstruction (FFBR). However, there are no reports on the effect of these two interventions relative to each other or combined.Methods: Abdominal based FFBRs performed by a single surgeon before introduction of either intervention were compared to those with VC only, and those after the addition of CTA to VCs (CT-VC).Operative time was defined as from "knife-to-skin" to insertion of the last stitch. Results: One hundred and twenty patients; 40 without intervention (WI), 40 with VC, and 40 with CT-VC. Introduction of VCs did not significantly reduce operative time compared to WI (P=0.73). However, patients in the CT-VC group had significantly shorter operations vs. WI (472 vs. 586 min, P<0.00001) and vs. VC alone (472 vs. 572 min, P=0.0006). Similarly, introduction of each intervention showed a stepwise decrease in ischaemia time (WI vs. VC: 100 vs. 89 min, P=0.0106; VC vs. CT-VC: 89 vs. 80 min, P=0.0307; WI vs. CT-VC: 100 vs. 80 min, P<0.00001).Conclusions: Combination of CTA and VC significantly reduced operative and ischaemic times for FFBR; this was predominantly due to use of CTA. CTA mitigates the surgical learning curve as demonstrated by shorter operating times via providing a vascular anatomy roadmap, thus facilitating flap harvest.

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Free flap surgery for breast reconstruction using abdominal, gluteal and thigh perforator flaps is now routine. It has been extended to "challenging" groups of patients such as the obese, the elderly, and those with multiple scars. However, bilateral free flap reconstruction is still demanding, especially when performed at the same time as the mastectomy. For healthcare staff new to bilateral immediate reconstruction-be they scrub nurses, technicians, junior doctors, or anesthetists-the operative process is not only lengthy but also confusing because it involves multiple steps and operating theatre teams. To simplify the process, we have designed flow charts that map out the course of the operations. We have found that these pictorial representations not only educate staff but also increase the efficiency of the entire procedure. This general principle of utilizing a flow chart to outline complex surgery can be applied to many different types of operations besides breast reconstruction.