The ideal scenario in deep inferior epigastric perforator (DIEP) flap dissection: a complete muscle and nerve-sparing approach

The deep inferior epigastric perforator flap (DIEP) has become the gold standard method of autologous breast reconstruction by simultaneously maximising aesthetics of the breasts and abdomen, and maximising the function of the abdominal wall. While the anatomical variability of the DIEP flap perforators have been well characterised, there has been less attention paid to the hierarchy of DIEP perforators in terms of limiting abdominal dysfunction post-operatively. In this paper, we seek to draw attention to what is, in our opinion, the ideal scenario in DIEP flap harvest. Where present, a medial paramuscular cutaneous vessel (MPCV) may be harvested using the pyramidalis separation technique enabling a complete rectus abdominis muscle-sparing and abdominal motor nerve-sparing approach. Herein, we describe the pyramidalis separation technique and the results in representative cases. In our experience, this technique enables an expeditious surgical procedure, and dramatically reduces damage to both muscles and nerves.