The DIEP Flap Revisit: A Cornerstone of Modern Autologous Breast Reconstruction Anatomy, Preoperative Planning, Surgical Technique, Outcomes, and Complications

Deep inferior epigastric perforator (DIEP) flap has become a standard of care in autologous breast reconstruction, offering reliable aesthetic outcomes and minimized donor site morbidity. Despite its advantages, substantial variability in perforator anatomy and intramuscular course presents technical challenges, and detailed knowledge, meticulous preoperative planning, and precise microsurgical techniques are the key to success. Advances in preoperative imaging, particularly computed tomography angiography (CTA), have enhanced perforator selection and flap design, improving operative efficiency and safety. DIEP flap reconstruction is applicable across a wide range of clinical scenarios, including immediate and delayed reconstruction, patients requiring or receiving irradiation, and those with low body mass index (BMI) or prior abdominal surgeries. Emerging innovations, including robotic-assisted flap harvest, image-guided navigation, and sensory neurotization, aim to further reduce donor site morbidity and improve functional and aesthetic outcomes. This review summarizes the anatomical foundations, surgical strategies, perioperative care, postoperative outcomes, and evolving techniques in effective DIEP flap breast reconstruction.