The deep inferior epigastric perforator flap: where we started and where we are now.

The deep inferior epigastric perforator (DIEP) flap has been performed since the early 1990s. This represented a significant advancement from the prior autologous options that required removal of all or a portion of various muscle groups. Over the years numerous advancements and modifications have been made to DIEP flap reconstruction that have further facilitated our ability to provide this option following mastectomy. Advancements with preoperative preparation, intraoperative techniques, and postoperative management have served to determine eligibility for DIEP flap reconstruction, improve surgical outcomes, reduce complications, reduce surgical operative time, and facilitate postoperative monitoring. Preoperative advancements have included vascular imaging to identify perforators. Intraoperative advancements have included using the internal mammary perforators as the optimal recipient vessels rather than the thoracodorsal, having a two-team approach with microsurgical reconstruction to reduce operative time and improve outcomes when compared to the single surgeon strategy, using a venous coupler rather than hand sewing the anastomosis, using tissue perfusion technology to determine the perfusion limits within the flap. Postoperative advancements include the use of technology to optimally monitor flaps as well as the use of using enhanced recovery after surgery pathways to improve the postoperative experience and promote early and safe discharge from the hospital. This manuscript will review the evolution of the DIEP flap as it relates to comparing our earlier techniques and strategies compared to our current techniques and strategies following mastectomy and breast reconstruction.