Navigating the Challenges of Deep Inferior Epigastric Artery Perforator (DIEAP) Flap Harvest in a Scarred Abdomen

Background The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard for autologous breast reconstruction, offering reliable perfusion and minimal donor-site morbidity. However, prior abdominal surgeries and scars may complicate flap harvest by altering vascular pathways, causing fibrosis, and limiting flap design. This study evaluates intraoperative challenges, outcomes, and patient-reported satisfaction in DIEP flap reconstruction in scarred abdomens. Methods A prospective observational study was conducted at a tertiary care plastic surgery center (2022-2024). A total of 20 female patients with visible abdominal scars undergoing immediate or delayed DIEAP flap reconstruction were included. All underwent CT angiography (CTA) for perforator mapping. Data collected included demographics, scar types, intraoperative findings, complications, and postoperative outcomes. The BREAST-Q reconstruction module scores were used to assess patient satisfaction. Results The mean age was 40.6 years (SD 8.9) with a mean hospital stay of 9.2 days (SD 2.9). Indications included invasive breast carcinoma (n=16) and phyllodes tumor (n=4). Scar types included Pfannenstiel (n=14), subcostal (n=6), periumbilical (n=3), and paramedian (n=2); seven patients had multiple scars. Intraoperative challenges included fibrosis, difficult perforator dissection, and restricted flap design. One index case with Pfannenstiel and periumbilical scars demonstrated superficial venous dominance requiring venous supercharging, which salvaged the flap. Recipient-site complications occurred in two patients (10%), and donor-site complications in four (20%). All flaps survived, with no total flap loss. The BREAST-Q scores demonstrated high psychosocial satisfaction (mean 81.5) and strong surgeon-related outcomes, though abdominal satisfaction was lower (64.8). Conclusions The DIEAP flap reconstruction in scarred abdomens is safe and effective, though scar pattern significantly influences planning and harvest. Preoperative CTA and intraoperative adaptability, including additional procedures like venous supercharging when necessary, enable excellent outcomes even in complex cases.