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

Introduction: Numerous minimally invasive deep inferior epigastric perforator flap (MI-DIEP) techniques have been described in 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 PRISMA guidelines to include articles with novel DIEP harvesting techniques. Studies without perioperative information were excluded. Chi square and Fischer exact test was 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 (JBI) 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 to 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). 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 robotic DIEP was linked to reduced postoperative day 1 pain (p<0.001). Conclusion/ Discussion: Minimally invasive DIEP techniques demonstrate comparable complication rates to conventional DIEP, with certain methods offering benefits such as reduced fat necrosis, shorter hospital stays, and less postoperative pain.