Neurotized DIEP Breast Reconstruction: A Feasibility Report of a Gap Length-Based Algorithm

Neurotization improves sensation after deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, although individual nerve reconstruction techniques are established, no published decision algorithm currently integrates postinset gap measurement with explicit gap-length thresholds for bridging strategy selection. Current intraoperative decision-making remains subjective and inconsistently documented, limiting reproducibility and cross-center comparison. We present a gap length-based decision algorithm and standardized nerve coaptation technique for neurotized DIEP flap breast reconstruction. After final inset, the tension-free gap is measured in millimeters in semisitting Fowler's position. Reconstruction is guided by defined thresholds: 10 mm or less, direct coaptation; 10-25 mm, nerve conduit (NerveTube, Integra; ~550 €); 25-70 mm, processed nerve allograft (Avance, Axogen; ~1200 €); and greater than 70 mm, autograft/cable-graft strategies. Each threshold is grounded in the established peripheral nerve reconstruction literature. In 13 consecutive patients (mean follow-up 10 mo), the algorithm was applied without neuroma formation, graft-site infection, or coaptation-related complications. This algorithm provides a reproducible, evidence-informed framework for intraoperative bridging decisions in DIEP neurotization. Preliminary data support feasibility and safety. Prospective sensory outcome validation is in preparation.