**Background:** Autologous breast reconstruction has become the gold standard for recreating the female breast after mastectomy, more than 40 years after the first description of the free abdominoplasty flap by Holmström. The field has evolved significantly, with the goal transitioning past flap success to maximizing aesthetic results and patient satisfaction while minimizing complications. This review aims to provide a concise overview of current trends and recent innovations in autologous breast reconstruction.
**Methods:** The authors screened conference abstracts from the London Breast Meetings (2015–2022) for content related to trends or innovations in autologous breast reconstruction. Forty eligible contributions were identified. For 25 contributions, an on-demand video was available on the Aesthetic and Reconstructive Breast Surgery Network (ARBS Network). After viewing, contributions were grouped into key areas in the preoperative, intraoperative, and postoperative setting. Additional literature was searched on MEDLINE.
**Key Results:** The findings are organized into three settings:
*Preoperative Setting:* Enhanced recovery after surgery (ERAS) protocols have been successfully implemented, including detailed patient education and expectation setting. Preoperative carbohydrate loading with maltodextrin-based drinks has been shown to slightly reduce length-of-stay (LOS) without increased adverse events compared with fasting or placebo.
*Intraoperative Setting:*
- **Efficiency:** Preoperative computed tomographic angiography was associated with decreased operative times in DIEP flap reconstruction. A cosurgeon approach reduced operative time, average LOS, and postoperative complications. In a retrospective review of 104 DIEP flaps with standardized protocols, average operative times were as short as 3 hours 21 minutes for unilateral and 5 hours 46 minutes for bilateral DIEP flaps. The venous coupler significantly reduced operation time compared with hand-sewn anastomosis.
- **Alternative Flaps:** The DIEP flap remains the first choice. For patients with insufficient abdominal tissue, multiple variations exist: the stacked hemiabdominal extended perforator (SHAEP) flap combines DIEP with a second pedicle; the APEX flap is safe when anatomical variations impair rectus muscle preservation; the low DIEP flap can reconstruct moderately sized breasts with a low scar. For non-abdominal candidates, alternative donor sites include the transverse myocutaneous gracilis (TMG), diagonal upper gracilis (DUG), profunda artery perforator (PAP), lateral thigh perforator (LTP), superior/inferior gluteal artery perforator, and lumbar artery perforator flaps. The lumbar artery perforator flap is considered superior to the DIEP flap in mimicking native breast shape and feel. Laparoscopically harvested omental flaps have been proposed to reduce donor site morbidity.
- **Surgical Technique:** Endoscopic perforator dissection using pediatric instruments has been described. Some authors routinely dissect internal mammary vessels without rib resection to reduce pain and prevent thoracic contour deformities. Barbed progressive tension sutures, alone or with suction drains, have been advocated for donor site closure. The CALP technique (progressive high-tension sutures with cannula-assisted lipectomy and limited flap undermining) was associated with significantly lower daily drainage output, fewer donor site complications, and better skin sensibility. Neurotization has gained attention and may restore sensation earlier and at lower stimulation thresholds.
- **Technology:** The robotic DIEP flap allows maximum pedicle length while limiting fascial incision to 1.5–3 cm. Two microsurgery robots exist: MUSA (Microsure) and Symani (MMI). Exoscopes have emerged as alternatives to surgical loupes and microscopes, offering improved ergonomics and superior 3D high-definition optics. Indocyanine green fluorescence angiography is useful for evaluating flap perfusion and preventing fat necrosis.
*Postoperative Setting:* Regional blocks have decreased postoperative opioid consumption and LOS. Preshaped Merino wool pads are a safe alternative to traditional heating blankets for selective warming. Red Bull Energy drink was associated with an increase in systolic blood pressure while having a diuretic effect on POD 1. ERAS protocols have enabled fast-track autologous reconstruction, with some authors performing breast reconstruction as an outpatient procedure with discharge as early as 23 hours postoperatively, without increased flap loss rate.
**Clinical Implications:** Autologous breast reconstruction has become the gold standard, with the focus shifting to maximizing aesthetic outcomes and patient satisfaction. Innovations in preoperative planning, surgical technique, alternative flaps, technology (robotics, exoscopes), and postoperative care (ERAS, early discharge) are enabling safer, more efficient, and more patient-centered care. The review is limited by its non-systematic methodology and reliance on conference abstracts, but it provides a valuable overview of the evolving landscape.