The Medial Paramuscular Approach to DIEP Flap Pedicle Dissection: Incorporating Rectus Diastasis Repair into Routine...

Area of Science:

• Plastic Surgery
• Minimally Invasive Surgery
• Microsurgery

Background:

• Deep inferior epigastric artery perforator (DIEP) flap harvest can lead to rectus abdominis (RA) muscle denervation and weakness.
• Conventional muscle-splitting techniques for DIEP flaps may require extensive muscle dissection, increasing the risk of iatrogenic nerve injury.
• Bilateral or bipedicled unilateral DIEP reconstructions are increasingly common, heightening concerns about post-operative muscle function.

Purpose of the Study:

• To describe a novel, minimally invasive technique for DIEP flap harvest that minimizes rectus abdominis muscle denervation.
• To present an alternative to robotic-assisted surgery for preserving motor nerve branches during DIEP flap harvest.
• To evaluate the effectiveness of a technique involving minimal fascial incisions and muscle splits around perforators.

Main Methods:

• A novel surgical technique involving minimal fascial incisions and muscle splits directly around target perforators.
• Dissection of the sub-muscular portion of bilateral deep inferior epigastric artery (DIEA) pedicles by sweeping under the medial borders of the rectus muscles.
• Utilizing longer midline or paramedian fascial incisions for flap harvest, which can be integrated into rectus muscle diastasis repair.

Main Results:

• The described technique preserves crossing motor nerve branches by dissecting the DIEA from its deep aspect.
• Muscle fibers are split minimally, directly around the perforator, thus reducing denervation of the lower rectus abdominis muscle.
• The technique is effective in minimizing abdominal wall injury without requiring additional specialized equipment.

Conclusions:

• This minimally invasive DIEP flap harvest technique effectively minimizes rectus abdominis muscle denervation and associated post-operative weakness.
• The described approach offers a viable alternative to conventional and robotic-assisted methods for preserving nerve integrity during DIEP flap surgery.
• The technique is particularly advantageous when concurrent repair of rectus muscle diastasis is planned, simplifying donor site closure.