A single-operator technique for DIEP flap raise in high-BMI patients

High body mass index (BMI) patients undergoing autologous breast reconstruction with the deep inferior epigastric perforator (DIEP) flap face the increased risk of wound healing complications, fat necrosis, and donor-site morbidity. While postoperative outcomes are well documented, the intraoperative technical challenges of flap harvest in this population are underreported. The heavy abdominal pannus complicates exposure, often necessitating experienced assistance and prolonging operative times. We describe a reproducible, single-operator DIEP flap harvest technique designed to overcome these challenges. The method involves limited incision and dissection to island only the required flap dimensions, sequential exposure down to fascia, and use of a suspension suture to secure the superior abdominal skin. Directional gravity and simple retraction thereby replace continuous assistant involvement. The superficial inferior epigastric vein (SIEV) is identified through a focussed longitudinal incision, eliminating the need for wide inferior pannus retraction. This approach minimises operator strain, reduces dependence on experienced assistance and provides controlled access to the flap perforators, as well as a long length of SIEV. In our experience, this technique has streamlined flap harvest, reduced surgeon energy expenditure, and shortened overall operative times in a technically demanding patient subgroup. By simplifying pannus management and optimising exposure, the technique enhances the safety, efficiency, and reproducibility of DIEP flap elevation in high-BMI patients. Adoption of this approach may broaden access to safe, autologous reconstruction for high-BMI patients and contribute to improved outcomes in this growing and often underserved population. LAY SUMMARY: A new surgical approach makes breast reconstruction using tummy tissue safe and easier for patients with higher BMI. It improves visibility during surgery, reduces operating time and effort, and may help more patients access successful natural-tissue reconstructions.