The medial paramuscular approach to DIEP pedicle dissection — incorporating rectus diastasis repair into routine donor-site closure

Authors: Hendrickson SA; Dusseldorp JR.

Affiliation: Chris O’Brien Lifehouse Hospital, Sydney, Australia.

Journal: Plastic and Reconstructive Surgery — Ideas and Innovations, October 2025

PMID: 40178538

Summary

The article describes a medial paramuscular (MPM) approach to deep inferior epigastric artery (DIEA) pedicle dissection performed from the deep surface of the rectus muscle via a midline or paramedian fascial incision. The technique aims to minimize intramuscular splitting and motor nerve injury while enabling routine rectus diastasis plication during donor-site closure.

Technique overview

• Preoperative CT angiography (CTA) for perforator mapping.

• Identification of medial-row perforators with a short intramuscular course and adequate caliber when using a single-perforator DIEP.

• Initial short fascial window around the target perforator (not paramedian/midline).

• Intramuscular perforator dissection through this "lateral" fascial incision.

  • Author recommends placing a vessel loop or glove to mark the intramuscular perforator

• Make a midline or bilateral paramedian fascial incision (often ~12–15 cm; Y-extension around the umbilicus as needed).

• Deep-surface dissection of the DIEA: ligation at the external iliac origin, caudal-to-cranial pedicle elevation, and delivery through the initial lateral fascial incision.

• Standard microvascular anastomosis to recipient vessels.

Closure strategy

• Lateral fascial incisions closed primarily.

• Routine rectus diastasis plication in epigastric, umbilical, and hypogastric zones to reinforce the midline and to imbricate/"hide" the long midline fascial incision.

• Mesh not used routinely; considered when preoperative examination suggests true abdominal wall weakness or hernia.

Evidence presented

• Five-year bilateral series reported lower clinically significant abdominal bulge after minimally invasive, deep-surface pedicle harvest methods (robotic or MPM) compared with traditional long intramuscular splits.

  • Traditional bilateral intramuscular split: 4/61 patients (6.6%) with clinically relevant bulge.

  • Minimally invasive (robotic or MPM): 0/32 patients (0%) with clinically relevant bulge.

  • Retrospective, nonrandomized series.

Novelty and context

• Deep-surface pedicle harvest and nerve-sparing principles are established in robotic DIEP. The contribution here is an open, nonrobotic method that seeks similar nerve-sparing advantages while integrating routine diastasis plication so that a long midline fascial incision does not translate into clinical morbidity.

• A midline-incision approach has been described elsewhere; this report formalizes a practical protocol pairing exposure with planned plication.

  • PMID: 39703378

Advantages

• Nerve-sparing pedicle harvest without robotic or other specialized equipment.

• Anatomically aligned with medial-row, short-course perforators favored in standard DIEP planning.

• Donor-site synergy: diastasis plication reinforces the midline and neutralizes the effect of the longer fascial incision.

• Useful for bilateral or bipedicled reconstructions where long muscle splits increase denervation risk.

Limitations and risks

• Evidence quality is limited to retrospective, noncomparative experience; outcome reporting combines robotic and MPM cohorts.

• Requires a substantial midline/paramedian fascial incision, with attendant risks (peritoneal entry, bowel injury) in reoperative abdomens.

• Benefit is anatomy-dependent; long intramuscular perforator courses may still necessitate more extensive splitting.

• Potential hemodynamic considerations of tight plication (e.g., intra-abdominal pressure) should be monitored; data specific to DIEP patients are limited.

Integration with abdominal wall reconstruction principles

• Midline plication converts diastasis into a reinforced linea alba, redistributing forces when tissue quality is acceptable and lateral closures are tension-appropriate.

• For true hernias or markedly attenuated fascia, a lower threshold for prophylactic mesh in a retrorectus or preperitoneal plane is reasonable, individualized to intraoperative findings.

Practical application

• Consider in patients with rectus diastasis ≥2 cm and favorable medial-row, short-course perforators on CTA, especially in bilateral or bipedicled cases or in centers without robotic capability.

• Plan the incision and plication together so that exposure and reinforcement are coordinated steps.

Bottom line

The MPM approach is a pragmatic, anatomy-driven open technique that seeks the nerve-sparing benefits of deep-surface pedicle harvest without robotics and couples exposure with routine diastasis plication to maintain donor-site integrity. It is useful when CTA demonstrates a medial-row dominant perforator with short intramuscular course, allowing a single-perforator DIEP. This represents yet another technique in the reconstructive armamentarium to minimize donor-site morbidity when patient anatomy allows.