Improving surgeon confidence in the DIEP flap: a strategy for reducing operative time with minimally invasive donor site.

Criticisms of the DIEP (deep inferior epigastric perforator) flap include difficulties in perforator identification and dissection and prolonged operative times. Likewise, the stress level in such harvests varies considerably, particularly in bilateral breast reconstruction where 2 successful flap harvests are mandatory. Various operative strategies were explored in 100s of DIEP flaps to refine the DIEP harvest from a safety, expediency, and musculofascial preservation perspective, both for total mastectomy and partial mastectomy applications. Ultimately, a strategy based on the antegrade pedicle dissection technique, usually with a single perforator harvest and discontinuous fascial incisions, has lead to a safer, more expeditious and minimally invasive DIEP flap harvest that is applicable in many cases. Flap harvest time is now generally on the order of one hour with significantly less stress and minimized fascial incisions. DIEP free flap harvest can be managed with greater confidence, reduced operative times and less muscle, and fascial invasion using the specific operative strategy of the antegrade pedicle dissection technique.