"The Medial Paramuscular Approach to DIEP flap Pedicle Dissection: Incorporating Rectus Diastasis Repair into Routine Donor Site Closure".

Abstract

Summary: Denervation of the rectus abdominis (RA) muscle during deep inferior epigastric artery perforator (DIEP) flap harvest may increase the risk of post-operative muscle weakness, particularly for the increasingly common bilateral or bipedicled unilateral reconstructions. 1-4 As the majority of large perforators arise in the para-umbilical region, fascia and muscle split lengths can be up to 15cm on both sides of the midline in order to harvest the full length of pedicle using conventional muscle-splitting approaches. 5,6 Robotic-assisted surgery enables laparoscopic harvest of the submuscular extent of the deep inferior epigastric artery (DIEA) from the deep aspect of the vessel and preserves crossing motor nerve branches, which travel superficial to it. 7 This minimally-invasive technique only splits muscle fibres directly around the perforator, minimising denervation of the lower rectus muscle.We describe a novel minimally-invasive technique requiring no additional equipment that is, in our experience, as effective at minimising abdominal injury. We propose minimal fascial incisions and muscle splits around the target perforators followed by longer midline or paramedian fascial incisions. This allows the sub-muscular portion of bilateral DIEAs to be dissected from their deep aspect by sweeping under the medial borders of the rectus muscles, thus avoiding the segmental motor nerves which cross superficial to the DIEA pedicle. This technique is particularly suitable when repair of a pre-existing rectus muscle diastasis is planned as part of the donor site closure, because the midline or paramedian fascial incisions are imbricated within the diastasis cavity, making this additional fascial incision almost irrelevant.