Limiting the fascia incision length in a DIEP flap: repercussion on abdominal wall morbidity

ABSTRACT Background : The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap, leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease. Methods : Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included. Each patient received a periumbilical EMG preoperatively, at six and fourteen weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009-May 2011. Results : In our LFI-technique, one vertical (4cm) incision is made where the pedicle exits the muscle. A second, oblique (3cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at respectively 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group. Conclusion : This study demonstrates the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function is less endangered using small segmental fascia incisions. We believe our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.