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Introducing the PRIME DIEP Flap: The Latest Evolution in Autologous Breast Reconstruction
Jenny Chen
*, Kevin McGarry, Seth Aschen, Jonas Nelson, Robert J. Allen
Plastic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
Background: The Deep Inferior Epigastric Perforator (DIEP) flap is a cornerstone of autologous breast reconstruction, offering durable and natural results. However, injury to the abdominal wall can lead to bulge, hernia, or functional deficits. To reduce donor-site morbidity, refinements such as fascial-sparing and robotic-assisted techniques have been developed. We introduce the Paramedian Reflection for Innervated Muscle Enhancement (PRIME) DIEP flap, a novel approach that minimizes muscle disruption, preserves innervation, improves pedicle exposure, and limits fascial closure to a midline plication.
Methods: From June 2023 to February 2025, patients undergoing DIEP reconstruction were evaluated with preoperative MRA. Inclusion required a single or closely grouped medial row perforator with a short (<4 cm) intramuscular course. After suprafascial elevation, a targeted fascial incision was made for intramuscular dissection. The incision was then extended inferomedially to the rectus medial border and continued inferiorly. The rectus muscle was mobilized laterally, exposing the pedicle via a paramedian approach, avoiding further muscle splitting and preserving motor nerves. Fascial closure was completed with midline plication.
Results: Eighteen PRIME DIEP flaps were performed. Mean patient age was 53.2 years; mean BMI was 26.6. Most reconstructions (77.8%) were delayed. Average flap weight was 631.7 g. A single perforator was used in 72.2% of flaps, with a mean diameter of 1.8 mm. One recipient site hematoma required evacuation; no flap loss, reoperation, or readmission occurred within 30 days.
Conclusion: The PRIME DIEP technique preserves rectus muscle and innervation while enhancing pedicle access. It offers benefits similar to robotic-assisted harvest without requiring specialized equipment or training. Further study is underway to assess long-term outcomes and donor-site morbidity.
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