Led by surgeon Suhail Kanchwala, MD, plastic and reconstructive surgeons have performed more than 120 Minimally Invasive Deep Inferior Epigastric Perforator (mi-DIEP) procedures at Penn Medicine.
The hallmarks of the mi-DIEP technique include a radical reduction in pain, quicker recovery to normal function, superior cosmetic results and the virtual elimination of the need for perioperative opioid medications. The majority of patients are managed with short hospital stays and over-the-counter medications.
The minimally invasive procedure begins at the time of mastectomy with the placement of a spacer in the breast and the initiation of a surgical delay, a procedure involving the identification of an abdominal perforator by CT angiogram. The ideal perforator is selected and all others are then ligated. This allows for the subsequent dilation and expansion of the deep inferior epigastric systems. The delay ensures that all patients are able to have surgery that avoids injury to the abdominal wall musculature.
Two to three weeks later, the vessel is retrieved through a reduced 1-2 cm incision in the fascia using either a laparoscopic or robotic approach similar to minimally invasive hernia surgery. A key contributor to successful outcomes has been a team approach with innovations in surgical technique paired with similar advances in anesthesia and postoperative care. All patients are enrolled in a coordinated Enhanced Recovery Protocol, which means that from the minute they enter the hospital, the focus is on recovery and getting back to normal as fast as possible.
A principal benefit of Dr. Kanchwala’s technique is its elimination of damage to the abdominal wall, a primary source of chronic pain during breast reconstruction surgery and recovery. Additionally, enhanced planning allows for a lower scar on the abdomen similar to that of cosmetic abdominoplasty. In cases of limited donor site volume the mi-DIEP procedure can be combined with a small implant to enhance shape and projection.
Mrs. M, a 47-year-old woman, was referred the Division of Plastic Surgery at Penn Medicine for a second opinion for bilateral mastectomy and reconstruction for breast cancer. An otherwise healthy and active woman, Mrs. M wanted an autologous breast reconstruction, but was concerned about the extended recovery associated with the standard DIEP procedure. After a consultation with Dr. Kanchwala involving a consideration of her options, she consented to have a mi-DIEP procedure.
A week later, Mrs. M returned for the first step of the two-step procedure. At this time, a bilateral mastectomy was performed, temporary spacers were placed, and the vessels surrounding two appropriate inferior epigastric perforators (previously identified by CT angiogram) were clipped. Mrs. M remained in the hospital overnight and importantly, was discharged the next morning needing only over-the-counter painkillers.
When Mrs. M returned two weeks later a laparoscopic total extraperitoneal (TEP) approach was used to harvest the flap and its vascular pedicle. This allowed a 2 cm incision in the fascia and muscle, drastically minimizing the amount of dissection. The flaps were then transferred individually with their perforators to the site of the earlier placed expanders and anastomosed to the right and left internal mammary arteries, respectively.
Mrs. M remained in the hospital for 36 hours for flap monitoring. Again, her pain was well controlled on over-the-counter medications. She was able to return to normal activities three weeks after surgery.
Penn Plastic Surgery Perelman
Perelman Center for Advanced Medicine
South Pavilion, 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104
Penn Plastic Surgery Plainsboro
Princeton Medical Center
Medical Arts Pavilion, Suite 300
5 Plainsboro Road
Plainsboro, NJ 08536
Plastic & Cosmetic Surgery
Lancaster General Hospital
554 North Duke Street, Ste 100
Lancaster, PA 17602
Penn Plastic Surgery Washington Square
Penn Medicine Washington Square
800 Walnut Street
Philadelphia, PA 19107
Published on: January 9, 2019
1. Carney MJ, Weissler JM, Tecce MG, Mirzabeigi MN, Wes AM, Koltz PF, Kanchwala SK, Low DW, Kovach SJ, Wu LC, Serletti JM, Fosnot J. 5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes. Plast Reconstr Surg. 2018;141:855-863. doi: 10.1097/PRS.0000000000004200.
About Penn Plastic Surgery
Penn Plastic Surgeons are recognized for their dedication to research and clinical care and for their collaboration with multidisciplinary teams and internationally-known specialists to provide patients with the highest quality complex care. Penn Plastic Surgery is the nation’s leader and among the world’s largest centers in clinical volume in reconstructive microsurgery (recently performing their 5,000th free flap reconstructive surgery.  Penn plastic surgeons recently took part in the first Bilateral Robotic Assisted DIEP flap procedure in the nation.
Penn Faculty Team
Chief, Section of Plastic Surgery, Virtua Memorial Hospital (Mount Laurel, NJ)
Clinical Assistant Professor of Surgery, Penn Medicine Lancaster General Health
Director of UIM Affairs, GME Office
Plastic Surgery Clerkship Director
Program Director, Penn Plastic Surgery Residency
Co-Director of Penn Hernia Center
Member and Co-director of the Penn Orthoplastic Limb Salvage Center
Chief, Penn Medicine Plastic Surgery