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

[BACKGROUND] 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.

[METHODS] 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.

[RESULTS] 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.

[CONCLUSION] 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.