Hand-performed minimal fascial incision DIEP flap breast reconstruction: A scoring system and early single-centre...

The deep inferior epigastric artery perforator (DIEP) flap remains the gold standard for autologous breast reconstruction. Traditional harvest techniques often require a large fascial incision that increases donor-site morbidity. Minimally-invasive approaches, such as robotic-assisted incisions, reduce this impact but introduce a steep learning curve and higher intra-operative costs. We aimed to detail our early experience in hand-performed minimal fascial incision (MFI) DIEP flap.

A retrospective review was conducted of DIEP flaps for breast reconstruction performed from June 2024 to December 2024 at a single centre in London, United Kingdom. Patients were grouped by incision types: standard (>6 cm) or MFI (≤6 cm). Baseline characteristics, preoperative imaging results, and postoperative outcomes were recorded for comparison.

The final cohort included 33 flaps (15 MFI and 18 standard incisions). The median length of stay was significantly lower in the MFI group [4 days (IQR 4-5)] vs. [5 days (IQR 4-6.25)], (p=0.036). The median number of perforators on a single row was significantly lower in the MFI group [1(IQR 1-2)] vs. [2(IQR 2-3)], (p=0.049). Mesh use was significantly higher in the standard incision group (p=0.001). There was no significant difference in operative time (p=0.128). The average MFI rectus sheath incision length was 4.59 cm. No donor-site complications occurred in either group.

A hand-performed MFI DIEP flap reduced hospital stay and mesh use, and was not significantly different in terms of operative time or complication rate to a standard DIEP flap. A scoring system was proposed to optimise patient selection for MFI. The hand-performed technique represents a key step in the surgical learning curve towards laparoscopic and robotic approaches. Further multi-centre prospective studies should be carried out to minimise performance bias and test the proposed framework.