The 24-hour DIEP challenge: How ERAS redefines recovery in microsurgical breast reconstruction

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols have reshaped perioperative management in microsurgical breast reconstruction. However, evidence supporting safe and reproducible ultra-early discharge following deep inferior epigastric perforator (DIEP) flap reconstruction remains limited. We evaluated a DIEP-specific ERAS pathway designed to facilitate 24-hour discharge. METHODS: A retrospective analysis of a prospective institutional database included consecutive patients undergoing unilateral/bilateral DIEP flap breast reconstruction between January 2023 and July 2025. Outcomes before (pre-ERAS) and after ERAS implementation were compared. The primary endpoint was length of stay (LOS); secondary endpoints included operative time, postoperative complications, and patient-reported satisfaction. Multivariable robust regression assessed the independent effect of ERAS on LOS and operative time. RESULTS: A total of 127 patients (143 flaps) were included (37 pre-ERAS and 90 ERAS). In unilateral reconstructions, LOS decreased from 3.69 ± 1.18 to 1.78 ± 0.80 days (p < 0.001), and in bilateral reconstructions from 6.00 ± 2.92 to 3.18 ± 0.60 days (p = 0.096). Twenty-nine ERAS patients (32.2%) were discharged within 24 h. Operative time was reduced in unilateral (-25.3%) and bilateral (-24.3%) reconstructions (all p < 0.001). ERAS was independently associated with a 50.9% reduction in LOS; body mass index was the only predictor of prolonged hospitalization. Complications rates did not differ between the groups. Patient-reported satisfaction was high and greater among patients discharged within 2 days. CONCLUSIONS: A structured ERAS pathway enables safe and reproducible 24-hour discharge following DIEP flap breast reconstruction without increasing morbidity. Standardized perioperative care and multidisciplinary coordination optimizes recovery, operative efficiency, and patient satisfaction.