How to approach the deep inferior epigastric perforator flap revision for optimal aesthetics

Introduction

Autologous breast reconstruction continues to evolve. With the deep inferior epigastric perforator (DIEP) flap now considered standard of care at most centers, the field has overcome the technical demands required to ensure consistent free flap survival while preserving muscle and minimizing donor site morbidity (1-3). Advances in imaging and microsurgical techniques have improved DIEP flap reliability and have allowed surgeons to anticipate perforator location, expediting dissection (2,3). Increased collaboration with our breast surgeon colleagues means that DIEP flaps can now be (and should be) consistently neurotized, which results in earlier, stronger, and more uniform return of sensation while only adding 8–38 minutes of operative time and without impacting donor or recipient site morbidity (4-8). Rib-sparing approaches minimize recipient site morbidity (9). With DIEP flap reconstruction, surgeons can now consistently provide women with a natural-appearing breast mound with minimal associated morbidity.

Concurrently, plastic surgeons have significantly improved the aesthetic outcomes of DIEP flap breast reconstruction. However, optimal results often require staged revisions to address volume discrepancies, asymmetries, and contour irregularities. Approximately 72% of patients undergo at least one revision, with younger age, prior oncologic surgery, and higher body mass index (BMI) linked to an increased likelihood of revision (10). The best way to minimize the number of stages needed to build an aesthetically pleasing breast is to perform a thoughtful reconstruction with aesthetics in mind. As such, this review article will look beyond revision techniques alone and highlight key principles that enable efficient, reproducible, and beautiful DIEP flap breast reconstruction.

Expectations and goal setting

The definition of an “ideal” breast varies from patient to patient and amongst surgeons. Aesthetic details can be difficult to articulate, making them challenging for patients to express and for surgeons to translate into surgical results (11-15). These challenges must be overcome in order to appropriately set expectations and understand each patient’s unique goals. Breast cancer patients often view plastic surgery as the silver lining to their cancer journey, and they must understand that breast reconstruction comes with its own risks and challenges. For every patient, it must be mentioned initially and repeatedly that for better or worse, a reconstructed breast will never be identical to a native breast. The concept of performing revisions after plastic surgery is also highly stigmatized, and patients must be made aware that most DIEP flap patients undergo at least one revision surgery, with a smaller population electing to undergo additional revision surgeries (10,16).

At the initial consultation, it is essential to thoroughly characterize each patient’s starting point. Openly discuss the patient’s current breast size and shape, highlighting any asymmetries, nipple areola complex (NAC) size, ptosis, scars, piercings, tattoos, and striae. Review autologous versus implant-based breast reconstruction principles and understand the patient’s perspective on both options; misinformation abounds, making preoperative education crucial. Discuss the patient’s ultimate reconstructive goals in terms of volume, shape, ptosis, and projection, and review potential donor sites needed to accomplish these goals. Understand her current BMI, goal weight, and weight stability, and explain how these factors influence reconstruction. The patient must understand the timeline, scar patterns, and possible complications associated with rebuilding an aesthetic breast. Understand each patient’s history of scarring, and anticipate wound healing risks based on BMI, future weight fluctuations, surgical and smoking history, diabetes, pathologic scarring, and other comorbidities. Nutrition should be optimized, and patients with a BMI >35 kg/m² should be referred to a weight management program preoperatively (17,18). It must be emphasized that autologous breast reconstruction is a staged process; the goal of the initial free flap surgery is first and foremost to rebuild a breast mound; additional surgery will be required to optimize cosmesis. Complications often negatively impact ultimate aesthetics, and it should be reinforced that strict adherence to postoperative protocols is essential to achieving an aesthetically pleasing result. While technologies exist to help patients visualize expected outcomes, many of their algorithms are designed to eliminate asymmetries; these technologies should be used cautiously to avoid creating unrealistic expectations. Traditional comparison of preoperative and postoperative photographs allows patients to set realistic expectations and begin to comprehend the steps in a typical reconstructive journey.

Preoperative computed tomography angiography (CTA) remains the standard of care for perforator mapping in DIEP planning. While this modality does not directly measure tissue perfusion, there is strong evidence to support that CTA provides a reproducible, operator-independent roadmap of perforator caliber, intramuscular course, and exit points, reducing dissection time (19-22). Widespread use of CTA has made routine DIEP flap delay uncommon, but a select role still exists for patients with high-risk abdomens, such as those with a high abdominal scar burden or vasculopaths, but current evidence is limited and non-standardized (23).

The initial consultation can often be overwhelming, and at least one additional preoperative clinic visit is recommended to ensure that expectations are clear and goals are mutually agreed upon. Scheduled follow-up visits every ~4–8 weeks from the initial consultation until the time of surgery are recommended. This is an excellent time to review preoperative CTA results and discuss incision planning and anticipated patient-specific challenges. And although there is a paucity of DIEP-specific data for prehabilitation, structured patient education inducing stress management and guided physical activity in breast surgery patients has been shown to improve readiness for surgery, enhance patient engagement, reduce anxiety, and even improve early recovery (24-26). While direct outcome data are sparse on joint consultations with both a patient’s breast surgeon and plastic surgeon, integrating multidisciplinary consultation is considered best practice in terms of aligning planning on oncologic and reconstructive plans.

Initial postoperative clinic visits focus on ensuring flap viability, promoting wound healing, and preventing complications. Each clinic visit is an opportunity to gauge a patient’s excitement and frustrations with her breast reconstruction process. It is expected that a patient’s priorities and goals will fluctuate throughout her reconstructive journey, and updated goals should be revisited and documented at each clinic visit. When patients desire additional breast volume, cleavage, and/or superior pole fullness, it is helpful to ask them to provide reference photographs (ideally of reconstructed breasts) to understand their exact goals; the words patients use to describe their goals can vary wildly from the reference photographs they provide.

Collaboration with breast oncology

Whether you are practicing in a multidisciplinary or private practice setting, each patient’s medical and surgical oncologic plan must be considered when counseling patients on aesthetic autologous breast reconstruction. Plastic surgeons should maintain open lines of communication with their breast surgery, breast oncology, and radiation oncology colleagues throughout the breast reconstruction process. Prior to definitively counseling a patient on her reconstructive plan, the surgical teams should discuss the feasibility and safety of preserving the NAC, decide on a mastectomy type, collaborate on incision planning, and prioritize intercostal nerve preservation. If oncologically safe, nipple-sparing mastectomy (NSM) improves postoperative sexual and psychological well-being compared to skin-sparing mastectomy (SSM) without increasing complications (27,28); these metrics reflect better patient-perceived breast aesthetics when the NAC is spared. In prophylactic cases with asymmetric or ptotic breasts, staged mastopexy or reduction should be discussed to improve nipple position prior to prophylactic mastectomy (18). Meanwhile, the medical oncologists should be engaged to strategically hold medications that inhibit wound healing. Radiation oncologists must also be intimately involved; whether determined preoperatively or after pathology results have returned, the need for radiation therapy plays a critical role in reconstructive timing. Some surgeons prefer to delay reconstruction until radiation is completed because of its deleterious effects on skin quality, fibrosis, contraction, and fat necrosis, while others prefer to perform delayed-immediate reconstruction with a tissue expander until the radiation plan is finalized (29-33). By designing each patient’s oncologic and reconstructive plan with all parties involved, realistic aesthetic goals can be agreed upon preoperatively.

The breast

Many factors of breast reconstruction are outside of the control of the plastic surgeon, such as non-modifiable patient factors and the need for radiation. However, by systematically approaching analysis, planning, and reconstruction, consistent aesthetic outcomes can be achieved. Blondeel et al. described a helpful, although limited paradigm for shaping the breast that considers the breast footprint, conus, and envelope (11-13). We see many parallels between autologous breast reconstruction and architecture. Therefore, we propose a new paradigm using architectural terminology: foundation, form, and façade. This architectural lens aims to help surgeons approach complex breast reconstruction with a consistent aesthetic vision, particularly in challenging secondary or delayed cases.

Foundation

The breast’s foundation is analogous to that of a house. Anatomically, the breast borders are the second rib superiorly, the sternocostal junction medially, the mid-axillary line laterally, and the inframammary fold (IMF) inferiorly (11,34). In many cosmetic breast operations, such as breast augmentations, the breast foundation goes undisturbed. However, in oncologic reconstruction, the breast surgeon often violates these borders to ensure oncologic safety (12,14). Preoperatively, note and mark discrepancies in bilateral breast foundations, especially the location of each IMF. In immediate reconstruction, the first step is to re-establish the breast foundation, typically by suturing the lateral and inferior mastectomy flaps to the chest wall. The senior author (A.J.S.) uses interrupted 2-0 monocryl sutures, avoiding superficial placement to prevent skin distortion and sparing the lateral intercostal nerves at the edge of the pectoralis muscle to avoid neuroma formation. The native breast foundation can also be adjusted to improve symmetry and optimize the aesthetic result. With the ideal foundation set, the goal breast width can be measured and translated into flap markings, ensuring the flap is wide enough to provide the necessary tissue volume and skin for chest resurfacing.

Foundation also includes the base of the breast, which is supported by the chest wall and pectoralis muscles. Some experienced microsurgeons argue that advanced techniques to access the recipient vessels—such as rib-sparing approaches to the fourth rib space—minimize the risk of creating a visible hollow in a thin or long-chested patient (18).

In delayed reconstruction, the breast’s foundation must be completely redefined. In the setting of prior chest radiation, irradiated skin inferior to the mastectomy scar typically needs to be excised full-thickness to recreate a natural lower pole during flap inset. Preoperative IMF markings are crucial; the IMF on the radiated side should be marked higher than on the non-radiated side, because removal of this stiff lower pole tissue tends to displace the fold inferiorly (3). The inferior force of the abdominal closure will further lower the fold. Some surgeons also advocate for leaving a 1cm cuff of skin along the IMF to prevent the skin paddle from looking “stuck on” the chest wall (18).

DIEP flap inset strategies vary depending on breast pocket characteristics. In immediate reconstruction with a large pocket, some surgeons advocate for fixing the flap to the chest wall with key tacking sutures to prevent lateral migration and improve superomedial fullness, whereas in delayed reconstruction, the pocket is carefully dissected with little need for suspension sutures. In tissue expander reconstruction, the capsule defines the breast pocket and must be strategically shaped, scored, released, and/or excised to recreate the appropriate breast foundation and allow for improved redraping. If rib cartilage is excised to access the recipient vessels, then the flap’s Scarpa’s fascia should be secured to the medial aspect of the resultant chest wall defect to minimize postoperative hollowing (18).

During staged revision surgery, the foundation is once again assessed and modified. The IMF can be elevated or lowered, and each breast can be widened or narrowed.

Form

A breast’s form is defined as its conus, shape, projection, and volume. With the foundation established, the flap must be shaped and inset. When designing the DIEP flap, it is prudent to leave the flap slightly larger than the patient’s desired size to account for potential future weight loss and the fact that the flap may need to be sculpted during secondary revision. The superior dissection can be beveled superiorly and laterally to capture additional tissue if needed (35).

Aside from the DIEP skin paddle used for monitoring, many surgeons prefer to de-epithelialize the remaining flap to preserve both volume and subdermal venous drainage, and to create a clear plane between the subcutaneous tissue of the mastectomy skin flap and the DIEP flap dermis for ease of dissection during secondary revisions. This technique preserves the sub-dermal plexus and does not appear to increase the incidence of fat necrosis (36,37). The senior author, however, believes that the remaining dermis can prevent the reconstructed breast from having a natural form, and therefore advocates for de-skinning instead of de-epithelializing the flap. While complete removal of the skin and dermis carries a theoretical risk of increased fat necrosis, no studies to date have conclusively quantified this risk in DIEP flaps (37).

For unilateral mastectomy patients with insufficient hemiabdominal tissue to achieve their size goals, the senior author prefers a stacked/conjoint DIEP flap with an intra-flap anastomosis (32,38). The same design principles apply: embrace the technical challenges, harvest only the necessary tissue, and maximize patient satisfaction. The resultant flap can then be shaped using a variety of techniques to improve projection. The lateral edges of the flap can be infolded to create a more conical, teardrop shape. Alternatively, a wedge of peri-umbilical tissue can be excised and the resultant tissue edges sutured together (3).

Surgeons have conflicting preferences in terms of DIEP flap inset strategies. The senior author advocates for the ipsilateral hemiabdominal flap to be rotated 180 degrees and inset with the medial aspect of the flap as the lateral portion of the reconstructed breast. This approach positions the superficial vein stump near the internal mammary vessels, allowing for primary anastomosis without vein grafting if additional venous drainage is required. The T12 sensory nerve branches are also found in the inferior half of the flap, and thus oriented so that the transected nerve endings are available for coaptation to the anterior T3 intercostal nerves within the microsurgical field (4,39). Alternatively, others prefer to rotate the ipsilateral flap 90 degrees so that the medial aspect of the flap is oriented as the inferior portion of the reconstructed breast, placing the thicker abdominal tissue along the inferior pole and the inferior abdominal tissue, which is considered more prone to fat necrosis, laterally, where firmness may be better tolerated or more easily excised. Finally, others prefer to inset the flap in the contralateral breast pocket, arguing that pedicle positioning is optimized (11,12,40). No matter which inset strategy is selected, consider sitting the patient up to ~45 degrees prior to final de-epithelialization/skin excision and inset to best assess flap position, projection, and symmetry (3).

Obtaining optimal breast form means minimizing fat necrosis. Intra-operative indocyanine green (ICG) angiography has consistently been demonstrated to be associated with reduced rates of fat necrosis and re-operation in DIEP flap breast reconstruction by revealing subclinical hypoperfusion, but given heterogeneity amongst ICG protocols and lack of randomized trials, for the time being ICG imaging is best employed liberally as an adjunct, especially in high-risk patients, and is not routinely required during DIEP flap reconstruction (41-47).

For additional volume, breast implants can be placed immediately or in a delayed fashion. The senior author does not place immediate implants and prefers to allow the flap(s) to settle, and then reassess patient goals as well as breast volume and symmetry at ~3–6 months postoperatively before considering implant placement.

Façade

The breast’s façade, or outermost appearance of skin and subcutaneous tissue, determines the shape of the breast together with the underlying foundation and form. The type of mastectomy performed significantly influences the resultant façade. As techniques and indications in breast surgery have evolved, preservation of the native skin envelope has become more commonplace. When indicated, SSMs and NSMs are widely considered oncologically safe and are now routinely performed in appropriate patient populations (48). When the breast’s entire skin envelope including the NAC can be preserved, the result is a more natural breast reconstruction with higher patient satisfaction and a comparable, low complication profile to that of SSM (49-51). Additionally, in patients undergoing prophylactic mastectomies, staged breast reduction and/or mastopexy ~5 months prior to mastectomy has also expanded the indications for NSM, with the added benefit of reduced rates of major mastectomy skin flap necrosis (52). When a NSM is performed through an IMF incision, a small skin paddle along the IMF is recommended for monitoring, which can later be excised at revision for a more aesthetic appearance of the fold (18). When the nipple is sacrificed, a circular skin paddle is recommended when possible, the size of which must account for staged nipple reconstruction (53,54). The entire skin paddle can then be concealed with a NAC tattoo, and the different quality of the abdominal skin compared to the breast skin results in a visually appealing reconstructed breast.

The need to reconstruct the breast’s façade varies dramatically between immediate and delayed reconstruction. In immediate reconstruction, if the mastectomy flaps are healthy and well-perfused, then there is rarely a shortage of chest skin. In cases of excess skin envelope, some surgeons advocate for strategic resection in either a vertical or Wise pattern to complement the shape of the flap and prevent early ptosis of the reconstructed breast; however, the main focus should remain on the form of the flap because relying on a skin brassiere alone will not produce a durable result (12,14,55,56).

In delayed reconstruction, there is often a skin deficit, or the skin may be retracted or scarred. When dissecting the breast pocket, especially laterally, constricting bands must be released to allow the façade to fully expand and avoid compressing the flap (11,12). To prevent the DIEP flap from adhering to the chest wall, the use of a tissue expander to prevent adhesions from forming between the skin and underlying pectoralis muscle, as well as techniques such as partial capsulectomy and placement of an intervening barrier—such as an acellular dermal matrix or biomesh—between the flap and chest wall may minimize dermal tethering and allow sliding motion (57–60).

Skin paddle design and inset significantly affect final breast cosmesis. In patients with prior chest radiation, the skin inferior to the mastectomy scar will likely be excised when creating the new breast foundation. It is prudent to delay excision until after successful flap anastomosis to avoid creating an open wound in a radiated field. This skin excision necessitates a significant amount of donor site skin to reconstruct the inferior pole of the breast, especially when attempting to create ptosis (34). This inset strategy creates a single aesthetic unit from the mastectomy scar to the IMF. In these cases, consider delaying flap deepithelialization until after tailor tacking its skin envelope in the anticipated inset location to ensure that there is sufficient skin for reconstruction. Alternatively, a small, circular or elliptical skin paddle can be positioned within the mastectomy scar at the center of the breast mound, creating two aesthetic units. As previously noted, this visually distinct central area can be used for staged NAC reconstruction. For patients with acceptable preoperative nipple position, some surgeons request SSM through a circumareolar incision, then inset the DIEP skin paddle into this round defect. The senior author argues that the former, single subunit approach creates a more visually appealing reconstructed breast when possible. In all cases, the dermis around the skin island can be safely incised to create smooth contours between the mastectomy flap, the skin paddle, and the surrounding chest wall skin (61).

Symmetry

While breast foundation, form, and façade should be considered separately for each reconstructed breast, ultimately, aesthetic outcomes depend heavily on achieving symmetry between the breasts. Despite advancements in DIEP flap aesthetics, we must remember that the primary goal of the first stage free flap operation is to create a breast mound. Asymmetries can only be partially corrected during initial reconstruction, and refinements are typically pursued during secondary revisions. Both breasts must be evaluated in light of the patient’s starting point and evolving goals throughout the reconstructive process.

Revisions typically involve selective volume removal by direct excision or liposuction, as well as repositioning using standard reduction mammaplasty and mastopexy techniques, with volume augmentation by fat grafting, regenerative injectables, and/or implant placement (62,63). Fat grafting is considered oncologically safe, and experienced breast radiologists can differentiate fat necrosis and related calcifications from findings consistent with malignancy (39,64-66). Surgeons typically wait at least 3 months between revision procedures to avoid compromising tissue viability. Fat grafting should be avoided in areas undergoing concurrent manipulation, as compromised perfusion may reduce graft take (63,67).

The nipple-areola complex

Following SSM, nipple loss, and/or staged nipple excision for oncologic indications, the breast is reduced to a mound of skin and soft tissue. It is no surprise that nipple reconstruction and NAC tattooing are associated with increased patient satisfaction as well as physical and psychosocial well-being, helping patients feel more connected to their reconstructed breasts (68). A reconstructed nipple creates a focal point and distracts from surgical stigmata including scars and skin paddles. Nipple reconstruction is usually offered only following completion of radiation, when the reconstructed breast mound has settled into its final position, all symmetrizing operations have been performed on the contralateral breast, and it too has been allowed to settle. Areolar tattooing occurs ~6 weeks after nipple reconstruction. Although projection is often emphasized, many patients prefer a smooth reconstruction and opt for a three-dimensional NAC tattoo instead, avoiding overprojection and eliminating the need for a bra to mask the nipple. For patients who wish to have their nipple reconstructed, the senior author prefers the keyhole technique, while others advocate for the C-V, C-Y, or Hammond flaps (53,54,69). As with every step of aesthetic revision surgery, the patient’s goals must be clearly understood and prioritized to determine the ideal approach to the NAC.

The abdomen

One major benefit of abdominally based breast reconstruction is that the donor site contour can be analogous to the result of an abdominoplasty. Just as patient expectations and surgeon goals for DIEP flap breast reconstruction have increasingly paralleled those of cosmetic breast surgery at the recipient site, the abdominal donor site result should also parallel the results of body contouring surgery. However, not all DIEP candidates would generally be considered to be abdominoplasty candidates, and it must be emphasized that during initial DIEP flap reconstruction, abdominal flap design is primarily meant to ensure a viable flap of adequate size for reconstruction can be harvested, and aesthetics are a secondary consideration. Nonetheless, careful planning of scar location and umbilical position as well as employment of modified body contouring techniques and closure methods can minimize the need for second stage revisions (3). Preoperatively, a patient’s relative torso length, umbilical shape and position relative to midline, abdominal asymmetries and contour irregularities, and the presence of hernias, diastasis, striae, and previous abdominal scars should be noted. As with an abdominoplasty, ideal scar placement is hidden and low, but no lower than 5–7 cm from the top of the vulvar commissure to prevent postoperative deformity. The planned incision should then extend laterally below the ASIS, usually no wider than the patient’s existing abdominal folds; importantly, the exact planned flap location should be determined to only take the amount of tissue the patient needs for reconstruction. While the revision rate for excision of lateral standing cones is much higher after DIEP flap than after cosmetic abdominoplasty, extending this incision to remove this excess lateral skin and soft tissue during initial free flap surgery has tradeoffs; drains can be brought out through this area knowing the drain scar will be excised at a later date, and these areas can also be “free” reservoirs of fat for subsequent fat grafting—many surgeons intentionally preserve this lateral tissue for these reasons (18,70-72). The upper abdominal incision can be marked using a pinch test, and the entire flap design may occasionally need to be moved superiorly in order to capture the peri-umbilical perforators and ensure tension-free closure, albeit at the cost of a higher scar; keep in mind that in select cases, once flap perfusion has been confirmed, the final scar position can be lowered during donor-site closure by placing the patient in slight reverse Trendelenburg or flexing the operating room table (73). Encouraging patients to wear undergarments or a swimsuit of their choice on the day of surgery can be helpful to ensure the scar is placed within this area, or to facilitate a conversation about why it will be placed outside of this area (74).

Alternative DIEP flap designs such as the low-rise DIEP flap, the low DIEP flap (for small-to-moderate breast reconstruction) and the mini-DIEP flap (for partial breast reconstruction) have been proposed to combat the problem of a visible, unappealing scar in patient populations without significant abdominal laxity (75-77). The low-rise DIEP flap is designed with a low skin paddle with a short vertical width that often does not contain a dominant perforator but results in a lower and shorter postoperative scar (76). The low DIEP flap relies on the presence of a dominant perforator 4 cm inferior to the umbilicus, and the flap is designed to have a resultant scar similar to that following a mini-abdominoplasty, with the added benefit of umbilical preservation (77,78). These alternative designs pose additional technical challenges for the surgeon, but with appropriate preoperative imaging and perforator selection, they increase our ability to provide patients with a low scar position and improved satisfaction.

The most common reasons for patient dissatisfaction with donor site appearance following DIEP flap reconstruction include lateral standing cone deformities, residual abdominal overhang, discrepancies in the thickness of the tissues above and below the abdominal scar, and poor scar location (70). New abdominal hernias and bulges after DIEP flap surgery are noted to occur at an overall rate of 0–7% and 2–33%, respectively (79-84).

During surgery, after committing to the superior incision, the dissection can be beveled cranially in order to both capture additional flap volume and to better match the thickness of the upper abdominal flap to the lower abdominal flap. To minimize abdominal wall morbidity, the fascial incision made during perforator harvest should be as short as possible, and motor branches of the intercostal nerves to the rectus abdominis muscle should be preserved (72). The extent of rectus dissection and intercostal nerve injury correlates with clinical morbidity (85).

Multiple retrospective series support that is rectus diastasis is present, concurrent anterior rectus sheath plication at the time of donor site closure improves abdominal contour without increasing surgical time, hospital stay, or reoperation rates (72,86,87). As with abdominoplasty and abdominal wall reconstruction cases, plication can theoretically increase intraabdominal pressure and threaten abdominal wall perfusion and stress the fascial repair; these small increases are usually well-tolerated unless baseline compliance is low, such as in obese patients and those with significant prior abdominal scarring (88-90). Although undermining to the xyphoid is often unnecessary to achieve tension-free closure of the DIEP donor site, the rectus abdominis muscle should be evaluated for diastasis prior to closure, and plication with permanent sutures should be considered to improve abdominal contour in patients with significant muscle separation (>3 cm). Although it is more time-consuming, especially in more active patients, the senior author advocates for the fascia to be reapproximated in an interrupted fashion instead of a running fashion, as postoperatively, at least anecdotally, patients are often bothered by the running suture line with daily movement and exercise. If a patient is noted to have poor quality abdominal fascia or atrophic, weak abdominal musculature that places them at high risk of postoperative hernia or bulge development, the senior author prefers to place a prophylactic onlay mesh, preferable one designed to distribute tension across the mesh itself, relieving tension on the fascial closure.

Ideally, the donor site scar will not require revision. Progressive tension sutures can be used to both obliterate dead scape and reduce tension on the incision, minimizing the risk of donor site scar widening and wound dehiscence while improving scar quality (91,92). After placing two 15 Fr drains, the senior author uses absorbable, barbed, running quilting sutures between the abdominal wall and abdominal flap, advancing the abdominal flap under tension along linea semilunaris prior to closing the skin incision. Scarpa’s fascia is then reapproximated from ASIS to ASIS, taking care to match the depth of the superior and inferior flaps. The skin edges are then reapproximated with atraumatic technique and perfect eversion of the dermis with absorbable deep dermal sutures, with some surgeons advocating for closure from the lateral to medial to minimize the risk of standing cone deformity (70). A deep running subcuticular layer with a barbed, absorbable monofilament is then used to perfectly reapproximate the epidermis.

One intraoperative strategy to decrease hematoma and drain burden without increasing venous thromboembolism risk is the use of tranexamic acid (TXA). This medication can be given intravenous or topically, and DIEP-specific prospective data are mixed regarding recommended dosing and route of administration. Selective employment of TXA in high-risk scenarios, such as in patients at high risk for bleeding and in revision cases, is generally supported by the literature (93-96).

If there is no postoperative bulge or hernia, then donor site revisions tend to focus on contour improvement, scar location, and umbilical aesthetics. Stalder et al. have proposed a standard staged approach for improving the DIEP donor site aesthetics in the right candidate. Approximately 3 months after initial free flap, they routinely perform liposuction of the superior abdominal flap, the mons, and the flanks, then lower the donor site scar to a location 4 to 7 cm above the vulvar commissure (depending on the height of the patient), which takes 27 minutes on average with aesthetically pleasing results and minimal wound healing complications. They also typically plicate and adjust the umbilical position at the first revision surgery (73). Others are not so prescriptive, but agree that mons liposuction and crescentic excision along the abdominal scar are reliable strategies to address concerns with mons contour and ptosis (18). In terms of abdominal contour, while DIEP flap donor sites used to result in a relatively flat abdominal contour, reconstructive surgeons are now borrowing techniques from the worlds of cosmetic abdominoplasty and high-definition body contouring; at the time of revision surgery, some surgeons attempt to transform the abdomen with liposuction, creating peaks and valleys to define the underlying anatomy and produce a more toned, athletic appearance. While some of these techniques could theoretically be performed at the time of initial DIEP flap reconstruction, and there is no “best” approach advocated for in the literature, most surgeons prefer to focus on microsurgical breast reconstruction during the first operation, then stage refinements. Abdominoplasty principles also counsel restraint at the time of primary closure to reduce seroma risk and wound tension, reserving high-definition liposuction for a well-perfused, settled abdomen (73,97,98).

Current evidence supports selective mesh reinforcement for high-risk donor sites, including wide fascial defects, as well as in patients with poor tissue quality and prior midline scars (99). Mesh utilization has been shown to reduce hernia risk but has not been shown to consistently lower bulge incidence (99,100). No single plane or mesh material is definitively superior in DIEP-specific data, leaving these decisions to the discretion of individual surgeons (99). If a ventral hernia or abdominal bulge develops postoperatively, the senior author takes a two-step approach to these revisions, first correcting the fascial laxity, then reinforcing the repair with mesh. It is important to perform a Valsalva maneuver to assess the fascial repair, ensuring not only that the repair provides enough strength that the bulge will not recur, but also that it is not too tight. Although uncommon, indications for referral to a hernia surgeon include very large ventral hernias, previously repaired hernias with existing mesh, and multiple unsuccessful attempts at hernia repair.

The umbilicus

The umbilicus should be routinely inset at least 7 cm above the final inferior scar, around the level of the ASIS, at a ratio of 1.675:1 from the xyphoid to the ideal umbilicus position to the pubic hairline (72). If the umbilical stalk is transected during elevation of the abdominal flap during either primary or revision surgery, it is recommended that after plication, the stalk is fixed to the rectus fascia in its desired position at midline in order to prevent drift and lateral malposition (73). Although the aesthetic umbilicus is considered a matter of personal preference to an extent, and many novel umbilical inset techniques have been described, a strategy must be selected to create a natural looking, unassuming umbilicus; the senior author prefers a “U-shaped” technique (101). Especially in thin patients or those with a relatively long umbilical stalk, the umbilicus can also be tacked to the abdominal fascial to create a natural-appearing area of depression. For patients with an unusable native umbilicus in terms of blood supply and/or cosmesis, a neoumbilicoplasty can be designed using a variety of techniques; there is data to support using an H-wing technique over an X-wing technique in order to maximize blood flow and minimize flattening (102).

Pain control

As poor pain control may provoke motion, stress, and bleeding, is prudent to optimize multimodal analgesia as part of enhanced recovery after surgery (ERAS) protocols to promote ideal aesthetic outcomes. Contemporary ERAS pathways for autologous breast reconstruction favor multimodal, opioid sparing approaches that include non-steroidal anti-inflammatory drugs (NSAIDs) and regional blocks—these regimens have been associated with decreased length of stay and narcotic use without increased complication rates (103-105).

Optimizing wound healing

After both the initial DIEP surgery and all revision surgeries, dressing selection and scar care are critical to aesthetic wound healing. Surgical glue, tape, or silk fibroin adhesive can provide additional tension offloading (106,107). Postoperatively, scar massage is started after incisions have completely healed (108). Scar taping should be initiated at the 4 week follow up visit, lymphatic massage of both the reconstructed breast and the abdomen should be initiated approximately 6 weeks after surgery when indicated and covered by insurance, and silicone sheeting should be initiated approximately 8 weeks after surgery as long as there are no areas of dehiscence or eschar (109). Creams containing human growth factors, interleukins, and other cytokines can be started concurrently (110,111). At least 8 months after surgery, pathologic and hyperpigmented scars can be assessed for laser therapy candidacy.

Silicone gel sheeting, topical clobetasol, and intralesional triamcinolone injections remain the mainstays for hypertrophic and keloid scar management (112,113). In the case that depressed, tethered scars develop at either the donor or recipient site, needle rigotomy and fat grafting is a powerful revision technique.

Typical revision timeline

In summary, following an aesthetically considered and highly individualized initial DIEP flap breast reconstruction, the senior author’s typical timeline for aesthetic DIEP revisions is as follows. Starting 8 weeks after surgery, scar therapy treatments commence. At 3 months after surgery, patients have a detailed symmetry consultation to discuss breast size and shape as well as abdominal contour and scar healing. All patient questions, concerns, and preferences are discussed. Patients are encouraged to be weight-stable for at least 2 months leading up to revision surgery. Most patients undergo at least one revision procedure at a minimum of 3–4 months after initial surgery, most commonly involving fat grafting from the abdomen and flanks to the reconstructed breast(s) coupled with needle rigotomy for scar release, excision of abdominal standing cones and drain scars, skin paddle excision, and nipple reconstruction. A smaller subset of patients then undergoes additional revision surgery, typically for repeat rounds of fat grafting. Representative photographs of a patient who underwent bilateral DIEP flap reconstruction and a single round of revisions are shown in Figure 1.

Figure 1 Preoperative and final postoperative photos of representative bilateral DIEP patient. Patient is a 53-year-old female with a strong family history of breast cancer and a personal history of left breast cancer who underwent bilateral nipple-sparing mastectomies and immediate bilateral rib-sparing DIEP flap reconstruction. Her pre-operative BMI was 22.2 kg/m². She wore a size 36D bra, and her goal was to be the same size or slightly smaller (left). Her abdominal donor site was closed with progression tension sutures, and the superior portion of each flap was anchored to the underlying pectoralis with interrupted 2-0 monocryl sutures. The lateral inframammary fold was re-established in the same fashion between the mastectomy flap and the underlying serratus. Approximately 7 months after her initial reconstruction, she underwent one round of revision surgery. Her primary goals were to improve superior pole contour bilaterally, address a small area of fat necrosis medially in the left breast, and improve abdominal contour irregularities. She underwent bilateral revision of reconstructed breasts with excision of skin paddles, direct excision of this single area of fat necrosis, fat grafting from abdomen and flanks to bilateral superior breasts (24cc to each breast), and right abdominal scar revision. She was last seen just over 2 months postoperatively and was very pleased with her results (right). The image is published with the patient’s consent. BMI, body mass index; DIEP, deep inferior epigastric perforator.

Challenges

There are a number of situations in which patients need to be counseled that more than one revision procedure will likely be necessary to achieve an ideal aesthetic breast reconstruction, including patients undergoing unilateral breast reconstruction, patients with a BMI outside of the 25–35 kg/m² range considered ideal for DIEP reconstruction, and patients undergoing radiation therapy.

Unilateral breast reconstruction patients

While the importance of noting a patient’s starting point preoperatively and the overall challenge of achieving symmetry between reconstructed breasts has already been emphasized, it is a unique challenge to match a native breast to a reconstructed breast. Specialized algorithms exist for optimal DIEP flap inset at the time of immediate unilateral reconstruction (114). Slim patients with relatively large breasts may also benefit from either harvesting flaps that cross the abdominal midline or harvesting bipedicled flaps to improve symmetry with the contralateral native breast (115). Interestingly, at least at some centers, undergoing bipedicled flap reconstruction has been shown to be an independent risk factor for undergoing multiple revision procedures (10). As with other revisions, most surgeons advocate for delaying contralateral symmetry procedures, waiting at least 3 months after initial unilateral DIEP reconstruction to pursue mastopexy, reduction, and/or fat grafting on the native breast to optimize symmetry.

High and low BMI patients

High BMI (defined as BMI >35 kg/m²) is a well-characterized risk factor that correlates with increased complication rates in autologous breast reconstruction, but no significant differences in flap survival (17,116,117). From an aesthetic standpoint, DIEP flap breast reconstruction in high-BMI patients leads to increased flap thickness, and especially in patients with small native breasts, can cause difficulty with inset and increases the risk for poor cosmesis. In these situations, superficial flap thinning techniques have been advocated for in the area of the flap that recreates the upper pole of the breast, as this approach allow for more favorable inset without the “step deformity” that has been associated with deep fat removal (118). This technique can also be combined with focused liposuction to improve the contour of the transition from the chest wall onto the superior pole of the reconstructed breast, but this option risks flap ischemia and contour deformity, and care must be exercised with infiltration of tumescent solution and deciding on the amount of tissue removed via liposuction. High BMI patients should also be counseled that they are more likely to need revision surgeries after a DIEP.

Slim patients (defined as BMI 20–24.9 kg/m²) pose a different set of problems. While this patient population can achieve successful and durable autologous breast reconstruction outcomes, they often require stacked flaps to address their relative lack of DIEP flap volume. Revisions for these patients most commonly involve staged fat grafting and/or breast implant placement (119-122). Depending on their body habitus and volume goals, these patients should also be counseled that they are more likely to need multiple rounds of fat grafting, typically with each session separated by 3–6 months (16). Patients with minimal excess adipose tissue can also benefit greatly from technological advances in the realm of regenerative injectables. In recent years, a number of off-the-shelf products ranging from sterilized cadaveric fat cells to decellularized allogeneic adipose matrices have entered the market, offering promising alternatives for volume augmentation at the time of revision surgery in slim patients (123-125).

Radiation therapy

As discussed above, adjuvant radiation prior to reconstruction significantly affects the breast foundation and facade, often requiring inferior pole skin excision and strategic inset of a large, single subunit abdominal skin paddle for optimal aesthetics. Depending on the timing, dose, and duration of radiation therapy, many cosmetic deformities that result from radiation are difficult to correct in subsequent revisions. Some studies suggest that radiation negatively impacts aesthetic outcomes and patient satisfaction, while others are inconclusive (29,33,126-128). Patients who undergo post-mastectomy radiation following immediate versus delayed DIEP flap reconstruction have been shown to have no significant difference in satisfaction, and not all patients are willing to delay reconstruction for an improved aesthetic result, leaving pathway selection up to joint decision making based on patient and surgeon preferences (128,129).

The specific effects that radiation therapy has on final DIEP reconstruction results can be somewhat predicted, allowing for compensatory measures to be taken during preoperative planning, marking, and flap design. Craig et al. compared DIEP flap volume, projection, and position on the chest wall in 11 patients who underwent immediate bilateral DIEP flap breast reconstruction and unilateral post-mastectomy radiation. This small cohort study found no significant changes in DIEP flap volume or projection, but noted that the position of the irradiated DIEP flap tended to be higher on the chest wall compared to the non-irradiated side (129). When the need for adjuvant radiation can be anticipated, some surgeons attempt to account for this asymmetry by lowering the IMF position accordingly. These patients should also be prepared for the likelihood of multiple revisions for optimal aesthetics.

As far as revision surgery in the irradiated breast, significant aesthetic improvements can be made using fat grafting and other regenerative injectables. Fat grafting has been shown to combat radiation skin changes and help restore radiated skin tissue quality (130-132). Decellularized adipose matrices have also been shown to alleviate radiation skin fibrosis, heralding an exciting area of future research and innovation (133). Representative photographs of a patient who underwent unilateral stacked DIEP flap reconstruction after radiation therapy and two rounds of revisions are shown in Figure 2.

Figure 2 Preoperative and final postoperative photos of representative unilateral, previously irradiated stacked DIEP patient. Patient is a 62-year-old female with a history of left breast in close proximity to the nipple areola complex. She completed neoadjuvant chemotherapy without significant response and then underwent a left skin-sparing mastectomy with sentinel lymph node biopsy and port removal followed by tissue expander placement, which was covered anteriorly with MTF FlexHD pre-pectoral pliable mesh. She received radiation therapy. Her pre-operative BMI was 23 kg/m². She wore a size 36D bra, and her initial goal was to be to be approximately the same size (left). Approximately 8 months later, after completion of radiation therapy, the patient underwent tissue expander removal, anterior capsulectomy, delayed left stacked neurotized DIEP flaps (the right lateral row vessels were anastomosed to vessel branches from the main left pedicle; an anterior cutaneous branch of T11 within the ipsilateral flap was coapted to the third anterior intercostal nerve using a Synovis nerve tube). The abdominal donor site was closed with 0 Quill progressive tension sutures. In the left breast, the lateral inferior mammary fold was re-created, tacking the mastectomy flap to the underlying serratus muscle with interrupted 2-0 monocryl sutures. The superior portion of the flap was secured to the underlying pectoralis muscle with interrupted 2-0 monocryl sutures. The skin paddle was designed to be positioned where her NAC had been located previously. Approximately 4 months after her initial reconstruction, she underwent one round of revision surgery. Her goals for this revision were to improve symmetry, be larger on the left, and address abdominal contour irregularities including a depressed area of her mid-abdominal incision. She underwent fat grafting from abdomen, flanks, and medial thighs to left breast (150 cc) focusing on the overall breast volume, rigotomy and fat grafting (25 cc) to mid-abdominal incision, bilateral abdominal standing excision, and right vertical mastopexy. Approximately 4 months later she underwent a minor procedure in clinic to revise a 4cm area of her left abdominal scar and to reconstruct her left nipple using the keyhole technique. She then underwent 3D nipple-areolar tattooing. At the time of her postoperative photos, her BMI was 22 kg/m². She was last seen nearly 3 years postoperatively and she is pleased with her results (right). The image is published with the patient’s consent. BMI, body mass index; DIEP, deep inferior epigastric perforator; NAC, nipple areola complex.

Conclusions

This review outlines practical strategies to guide surgeons in achieving consistently high-quality aesthetic results following DIEP flap reconstruction. It is retrospective and reflects the senior author’s preferred techniques and architectural approach for optimizing aesthetics in DIEP flap breast reconstruction and staged revision surgeries and is therefore a limited overview not meant to be comprehensive. Outcomes have been previously published (32,39,134).

As the DIEP flap has become the gold standard for autologous breast reconstruction, refinements in technique and postoperative revisions have become increasingly focused on optimizing aesthetic outcomes. Aesthetic success relies on strategic planning at every stage—from flap design and inset to donor site closure and scar management. Revision procedures such as high-definition liposuction, fat grafting, and NAC reconstruction offer powerful tools for improving contour and symmetry. For patients with prior radiation, high or low BMI, or unilateral reconstruction, tailored approaches are essential to address unique challenges. Of course, all of these techniques must be implemented in alignment with local policies, funding structures, and institutional capacity, recognizing that access to staged aesthetic revision and advanced techniques may vary across healthcare settings. By incorporating aesthetic principles, managing patient expectations, and staying attuned to emerging technologies, surgeons can elevate outcomes beyond flap survival to achieve results that help patients restore both form and confidence.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Sarah N. Bishop) for the series “Aesthetic Breast Reconstruction” published in Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-352/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-352/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. A.J.S. worked to develop FlexHD Pliable PRE^® acellular dermal matrix and serves as a preceptor for this product for MTF Biologics. There are no other potential conflicts of interest with respect to this research, authorship, and publication of this article. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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