Have Outcomes Improved in Microsurgical Breast Reconstruction? An 8-Year Prospective Longitudinal Study of 5,671 Flaps Across 22 Centers

Background: Prospective national registry data provide a unique opportunity to evaluate whether increasing experience and structured certification translate into improved microsurgical breast reconstruction outcomes over time. Methods: All microsurgical free-flap breast reconstructions recorded in the prospective quality assessment database of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) between 2011 and 2018 were analyzed. Data from 22 certified centers were included. Temporal trends in flap selection, operative parameters, and clinical outcomes were assessed at national, center, and surgeon levels. Results: A total of 5,671 microsurgical flaps in 4,909 patients were evaluated. Overall flap-loss rates remained stable throughout the study period (2.6–4.2%, p=0.894) despite increasing center participation and surgeon experience. Additional flap techniques were gradually introduced; however, diversification remained limited with heterogeneous uptake across centers, and DIEP remained the predominant reconstructive option. Operative duration decreased significantly in high-volume centers (mean difference −38 minutes, 95% CI −69 to −7; p = 0.020) and among more experienced surgeons (mean difference −30 minutes, 95% CI −49 to −11; p = 0.003), but no overall reduction in operative duration was observed over time. In contrast, ischemia time showed an overall trend toward prolongation. Conclusion: Microsurgical breast reconstruction within a nationwide network of certified centers achieved consistently high and internationally comparable outcomes. Despite increasing institutional experience and the introduction of additional flap techniques, flap-loss rates remained stable and DIEP remained the predominant reconstructive option. Although learning-curve effects were identifiable at both the institutional and surgeon level, they did not translate into further reduction in complications. Further quality improvement is therefore more likely to benefit from structured benchmarking and regular feedback of operative and outcome metrics than from technical refinements alone.