BACKGROUND: Standard of care in flap reconstruction of the breast should reflect that procedure which most plastic surgeons can perform safely in most communities, namely pedicled TRAM flap. However, more optimal care may be delivered if improved blood supply to the flap results in less fat necrosis, such as in the TRAM free flap, or if muscle and fascia preservation maximize abdominal wall integrity and strength, such as in the DIEP free flap. Criticisms of the DIEP flap include difficulties in perforator identification and dissection and prolonged operative times. Strategies in operative technique that allow for confident identification and protection of critical perforators, reduced dissection time and minimally invasive muscle and fascial incision will be presented.
METHODS: During the performance of hundreds of TRAM free flaps, anatomic patterns and variations in the deep inferior epigastric pedicle were noted and utilized to incrementally diminish the amount of muscle and fascia harvested. Flap harvest times were generally under 30 minutes with high confidence in flap vascularity. Eventually the author's approach evolved to DIEP free flap (except in rare cases of SIEA pedicle hypertrophy) in the interest of total musculofascial preservation. DIEP flap harvest times have varied considerably from 45 minutes to 2.5 hours depending on perforator number, size, intramuscular course and distribution. Likewise, the stress level in such harvests varied considerably, particularly in bilateral breast reconstruction where 2 successful flap harvests are mandatory. Various operative strategies were explored in hundreds of DIEP flaps to refine the DIEP harvest from a safety, expediency and musculofascial preservation perspective, both for total mastectomy and partial mastectomy applications.
RESULTS: Ultimately, strategies based on retrograde pedicle dissection, single perforator harvest and discontinuous fascial incisions have lead to a safer, more expeditious and minimally invasive DIEP flap harvest that is applicable in many cases. Intraoperative photodocumentation will be presented for demonstration of such techniques. Flap harvest time is now generally on the order of one hour with significantly less stress and minimized fascial incisions.
CONCLUSIONS: DIEP free flap harvest can be managed with greater confidence, reduced operative times and less muscle and fascial invasion if specific operative strategies are employed. This should allow for increased acceptance and greater utilization of DIEP flaps by more plastic surgeons.