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J Reconstr Microsurg
DOI: 10.1055/a-2659-6939
Original Article

Optimizing Donor Site Morbidity in DIEP Flap Reconstruction: Advancements in Minimizing Anterior Fascial Defects: A Systematic Review

Diwakar Phuyal
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Isaac Mordukhovich
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
James Gaston
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Arturo J. Rios-Diaz
2   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Osama Darras
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Rommy Obeid
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Risal Djohan
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Graham Schwarz
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
,
Raffi Gurunian
3   Department of Plastic and Reconstructive Surgery, Cleveland Clinic Abu Dhabi, United Arab Emirates
,
Sarah N. Bishop
1   Dermatology and Plastic Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract

Background

Numerous minimally invasive deep inferior epigastric perforator flap (MI-DIEP) techniques have been described in the literature to reduce donor site morbidities. This systematic review aimed to summarize existing MI-DIEP techniques and postoperative outcomes relative to conventional harvest (cDIEP).

Methods

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to include articles with novel DIEP harvesting techniques. Studies without perioperative information were excluded. Chi-square and Fisher's exact test were used to compare complication rates (partial flap loss, total flap loss, hernia or bulge, and fat necrosis) in MI-DIEP with cDIEP. Joanna Briggs Institute critical appraisal tool was used for bias assessment.

Results

A total of 978 patients underwent 1,272 MI-DIEP flap harvests across 17 studies. Techniques included robotic DIEP (rDIEP; n = 97), abdominal perforator exchange (APEX; n = 158), laparoscopic (n = 39), endoscopic (n = 94), two-staged delayed DIEP (n = 135), short fasciotomy (n = 124), short pedicle (n = 26), vascular pedicle measuring (n = 209), and microfascial incision (n = 81). No significant differences were found between endoscopic, laparoscopic, and robotic approaches compared with cDIEP. However, the short pedicle technique had higher partial flap loss (8.82% vs. 1.98%, p = 0.04), while APEX and vascular pedicle measuring techniques had lower fat necrosis rates (1.99% and 0.48% vs. 5.81%, p = 0.04 and 0.004 respectively). Short fasciotomy was associated with higher fat necrosis (12.9% vs. 5.8%, p = 0.004) and longer hospital stay (p = 0.005). Robotic, laparoscopic, endoscopic, two-staged, and APEX techniques were associated with shorter hospital stays, and rDIEP was linked to reduced postoperative day 1 pain (p < 0.001).

Conclusion

MI-DIEP techniques demonstrate comparable complication rates to cDIEP, with certain methods offering benefits such as reduced fat necrosis, shorter hospital stays, and less postoperative pain.

Keywords

DIEP - deep inferior epigastric artery perforator flap - robot - laparoscopic - endoscopic - minimally invasive techniques - totally extra peritoneal - transabdominal preperitoneal

Supplementary Material



Publication History

Received: 25 January 2025

Accepted: 24 June 2025

Accepted Manuscript online:
18 July 2025

Article published online:
25 August 2025

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