Inset techniques for the DIEP flap – what improves aesthetic outcomes?

Introduction

The deep inferior epigastric perforator (DIEP) flap is a workhorse for breast reconstruction. A critical aspect of this procedure is the inset technique, which determines the flap’s final contour and shape, and as such both the aesthetic and clinical outcome. Residents and novice plastic surgeons often go through their own evolutionary process before settling to a particular inset technique and approach. To date, there are several nuances to flap insetting and no agreed gold standard approach. This review will summarise the existing body of evidence related to DIEP flap insetting techniques to guide plastic surgery residents and surgeons at the beginning of their careers.

Evaluation of the topic

A systematic review was performed according to PRISMA guidelines. The methodology is outlined within our published protocol (Prospero CRD42023449477). A total of 803 records were screened (Scheme 1). Six articles were included in this review, with a total of 346 patients and a follow-up ranging from 6 months to 4 years [1–6]. A summary of included studies and results can be found in Tab. 1 and 2 respectively.

Gravvanis et al. (2015) conducted a randomized controlled trial to investigate whether single or dual-plane inset was superior, whilst adhering to the single aesthetic unit principle (Fig. 1) [1]. Dual-plane flap inset was found to have minor scarring, a more natural transition, better breast contour, better overall breast appearance and higher patient satisfaction scores (P < 0.05). The authors went on to present a prospective case series of patients with dual-plane inset in 2016, revealing high patient satisfaction at 2 years post-surgery, especially with regards to upper pole fullness and minimal ptosis with time [2].

Razzano et al. (2019) presented a prospective case series of 70 patients describing their novel insetting algorithm [3]. The flap was positioned vertically in patients with ptotic contralateral breast or slim abdomen, or horizontally if there was a projected contralateral breast or fat abdomen. The flap was also rotated either 90 or 180 degrees depending on the number and length of the pedicles and requirement for ptosis. The authors revealed a mean overall BREAST-Q score of 82, representing excellent patient satisfaction. Atzeni et al. (2022) performed a case-control study on patients operated on using the Razzano protocol, and those operated on without the algorithm [4]. They showed that the insetting algorithm had reduced the need for revision procedures (34 vs. 72 revisions in the control group; P < 0.05).

Francis et al. (2022) presented a prospective case series of 24 patients, looking at the need for a skin paddle vs. delayed primary retention suture (DPRS) (Fig. 2) [5]. At 12 months of follow-up, the overall Manchester Scar Scale in the DPRS group was statistically superior to the skin paddle group (P = 0.04). They found no significant difference in complications, including infection.

Dung et al. (2023) reported a case series of 40 patients with oblique inset of the DIEP flap [6]. BREAST-Q results revealed good aesthetic results and an average satisfaction score of 62, although total flap necrosis was seen in 3 patients (7.5%) and delayed wound healing in 2 patients (5%).

Conclusion

Although DIEP flaps are considered a workhorse for breast reconstruction, the number of revision surgeries for breast asymmetry is still high worldwide [7]. Optimising the procedure, including the inset level, may reduce revision surgeries. Although limited by the availability of well-designed research and sample sizes from the available evidence, the single aesthetic unit principle, dual-plane inset and elimination of the need for a skin paddle (such as using DPRS) all lead to superior aesthetic outcomes. Flap positioning (vertical, horizontal or oblique) and rotation, depending on the abdominal fat content or the degree of ptosis in the contralateral breast can also aid in optimising aesthetic outcomes. The presence of algorithmic insetting may also improve outcomes. Limitations of this review include a small sample size of patients and a small number of studies. There is also lack of robust evidence to suggest a gold standard way of insetting a DIEP flap and there is no one technique particularly superior to others. Surgeons must consider individual patient aesthetic needs and tissue characteristics to formulate a tailor-made solution for their patient.

Roles of authors

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