Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction

Summary: Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm–1.2 mm). The average vein diameter was 2.0 mm (1.5–3.0 mm). The incision to closure lasted 330 minutes (313–348 minutes). Flap ischemia was 105 minutes (82–118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22–30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.