The Midline Approach to Bilateral DIEP Flap Elevation: A Paradigm Shift to Improve Postoperative Integrity of the Abdominal Wall.

Abstract

The goal of optimizing abdominal wall preservation with DIEP flap breast reconstruction has renewed attention to technical refinements. This study introduces 4 novel fascial incision patterns that allow pedicle exposure and dissection from the midline to preserve the rectus muscle and fascia. All patients undergoing bilateral DIEP flap breast reconstruction (144 flaps in 72 patients) by a single surgeon over a 1-year span were prospectively evaluated. One of 4 fascial incision patterns, all of which utilize a midline approach to expose the pedicle, were applied: Y-pattern, hockey stick pattern, 3-incision, or modified Pfannenstiel. Selection, safety, efficacy, and outcome of these techniques were examined. Seventy-one percent of patients were able to utilize a midline approach. While the Y-pattern incisions were used most commonly in the beginning, 3-incision and modified Pfannenstiel incisions were favored later on. Indications for the standard lateral approach (29%) included need for multiple perforators and excess midline scarring. The overall rate of complications (3.5% take back rate for 3 hematomas and one incident of flap congestion) was comparable between the midline and lateral pedicle exposure (2.9% vs 4.7%); No abdominal bulge or herniation was observed in the follow up period. In the majority of patients undergoing bilateral DIEP flap breast reconstruction, a midline pedicle exposure with minimal lateral fascial and muscle incisions can be utilized. The technique can be done in a safe manner to help minimize abdominal donor site morbidity and has resulted in a paradigm shift in how we approach this procedure.