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Open Access
CC BY 4.0 · J Reconstr Microsurg Open 2025; 10(02): e32-e38
DOI: 10.1055/a-2751-8845
Original Article

Introducing the PRIME DIEP Flap: The Next Evolution in Autologous Breast Reconstruction

Authors

  • Kevin M. McGarry

    1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States

  • Jenny Chen

    1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States

  • Seth Z. Aschen

    1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States

  • Jonas A. Nelson

    1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States

  • Robert J. Allen Jr.

    1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States

Funding Information This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748, which supports Memorial Sloan Kettering Cancer Center's research infrastructure.
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Abstract

Background

Following its initial description in 1994, the deep inferior epigastric perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. While sequential modifications have improved patient outcomes, functional donor site morbidity, abdominal bulge, and hernia remain a challenge. Techniques such as robotic surgery show promise in mitigating these issues but are limited by the need for specialized equipment and training.

Methods

The Paramedian Reflection for Innervated Muscle Enhancement (PRIME) DIEP flap is a novel technique that preserves innervated rectus muscle and minimizes fascial disruption without requiring robotic assistance for flap harvest. Patient selection is based on preoperative imaging, identifying a suitable dominant medial row perforator(s) with a short intramuscular course. A limited fascial incision over the perforator, followed by a paramedian fascial extension, medial reflection of the rectus abdominis, and submuscular pedicle dissection, allows for safe visualization while minimizing abdominal wall morbidity.

Results

Between June 2023 and February 2025, 15 patients underwent 18 PRIME DIEP flaps. All flaps survived, with one patient requiring reoperation for hematoma. There were no flap losses, readmissions, or donor site complications, such as bulge or hernia, at 30-day follow-up. About 72.2% of flaps were based on a single perforator, with an average flap weight of 631.7 g.

Conclusion

The PRIME DIEP flap represents the next evolution in autologous breast reconstruction by offering a reproducible, muscle- and nerve-sparing technique, enhancing abdominal wall function in suitable patients. This technical modification also allows for the incorporation of the fascial closure in a midline plication, which may improve vascularity of the fascia following DIEP flap harvest. Further prospective studies are underway to evaluate the impact on long-term functional outcomes and further refine patient selection criteria.

Keywords

DIEP flap - PRIME DIEP - abdominal wall morbidity - autologous breast reconstruction


Publication History

Received: 19 June 2025

Accepted: 02 November 2025

Accepted Manuscript online:
21 November 2025

Article published online:
09 December 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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