Introduction: The free TRAM or DIEP flap remains the gold standard for breast reconstruction but many factors contribute to its under-utilization: lengthy operative times, physical demands, declining reimbursements, and strained healthcare resources. We have implemented measures to improve efficiency and maintain clinical outcomes.

Objective: To perform an outcome analysis of a series of TRAM and DIEP flap breast reconstructions over an eight year period in a community hospital setting, evaluating whether implementation of clinical pathways and increases in operative volume have led to improved outcomes and efficiency.

Methods: 586 consecutive patients undergoing breast reconstruction with 704 free TRAM or DIEP flaps were reviewed for operative times, length of hospital stay, microsurgical anastomosis times, and morbidity. Data were compared during three one-year periods, 1996, 1999, and 2002, during which technical and clinical improvements were made. Groups were compared using two-tailed t-test to determine statistical differences set at p<0.05. Data are presented as means ± SD. Results: 48 free TRAM procedures were performed in 34 patients in 1996 prior to the initiation of clinical pathways. During period two 106 free TRAM procedures were performed in 87 patients. Further refinements were made in clinical pathways in period three (157 free TRAM flaps in 117 patients). The incidence of diabetes, obesity, and smoking were not statistically different between groups. Operative times were reduced from 6.7 + 0.4 hours (gp 1) to 4.9 + 0.4 (gp 2) to 3.25 + 0.7 (gp 3). Corresponding decreases in ischemia times were seen from 49 + 6 minutes (gp1) to 33 + 5 (gp2) to 24 + 4 (gp 3). Complication rates were not statistically different between groups 23% (gp 1), 17% (gp2), and 18% (gp 3) (p> .05) nor flap loss rates 0% (gp1), 0.9% (gp2), 1.3% (gp 3) (p=ns). Hospital stay decreased from 4.2 days (gp1) to 3.4 days (gp2) (p<0.05) remaining constant thereafter in gp 3 (3.7 d, p= ns).

Conclusion: Operative times, microsurgical times, and length of stay can be improved by standardizing clinical pathways for the free TRAM flap. In this study we illustrate that a well-equipped team in a community hospital following well designed clinical pathways can decrease free TRAM flap operative times to just over three hours, flap ischemia times to under 25 minutes, length of hospital stay to under 4 days, and obviate the need for ICU monitoring while maintaining excellent patient outcomes. Team and institutional efforts will be discussed.