How to approach the deep inferior epigastric perforator flap revision for optimal aesthetics

Deep inferior epigastric perforator (DIEP) flap reconstruction has become the gold standard for autologous breast reconstruction, offering favorable outcomes in terms of flap viability and breast aesthetics. However, optimizing both donor and recipient site cosmesis initially and during postoperative revisions remains a critical component of patient satisfaction. This review provides an overview of strategies to enhance aesthetic outcomes in DIEP flap reconstruction, emphasizing donor site contouring, revision timing, and approaches tailored to challenging patient populations. To guide a systematic and intuitive framework for designing the breast, we introduce updated terminology rooted in architectural design: Foundation, Form, and Façade. The initial DIEP flap sets the stage for all subsequent revision surgeries. Preoperatively, key considerations include detailed preoperative assessment and patient expectation management. Intraoperatively, DIEP flap design and inset must be performed with aesthetics in mind. At the donor site, strategic abdominal incision placement and utilization of cosmetic closure techniques are crucial to mimic abdominoplasty results, and methods to preserve or reconstruct the umbilicus for a natural appearance are discussed. Initial postoperative management focuses on modalities to enhance scar healing. Revisions are typically initiated 3-4 months postoperatively and involve procedures such as skin paddle excision, liposuction and fat grafting, excision of standing cones, scar release and revision, and nipple-areola complex reconstruction. Special attention is given to patients with a high or low body mass index (BMI), those undergoing unilateral reconstruction, and individuals receiving radiation therapy, outlining specific approaches to address these unique challenges. Emerging technologies are explored as adjuncts to improve outcomes in patients with limited donor tissue and/or compromised skin quality due to radiation. By integrating principles from cosmetic surgery and employing a patient-centered approach, surgeons can enhance both the aesthetic and functional results of DIEP flap breast reconstruction. This review serves as a practical guide for clinicians aiming to refine their techniques and achieve optimal outcomes in complex reconstructive scenarios.