The Role of the Abdominal Perforator Exchange (APEX) Technique in the Perforator Selection Algorithm for Delayed Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

<b>Background</b>: The deep inferior epigastric artery perforator (DIEP) flap is currently the most widely used method for autologous breast reconstruction. Its primary advantage over the transverse rectus abdominis muscle (TRAM) flap is the reduction in donor-site morbidity, as it preserves the integrity of the abdominal muscles and motor nerves. Importantly, each patient's unique vascular anatomy requires an individualized approach to perforator selection and the surgical technique. <b>Objective</b>: We aimed to minimize donor-site morbidity and refine the perforator selection strategy in delayed DIEP flap breast reconstruction using the abdominal perforator exchange (APEX) technique. <b>Materials and Methods</b>: In this study, we prospectively and retrospectively analyzed the use of the APEX technique in patients undergoing delayed DIEP flap breast reconstruction between April 2020 and October 2024. All patients underwent preoperative non-contrast magnetic resonance angiography of the donor area. A total of 106 patients were enrolled and divided into two groups: 34 patients underwent reconstruction using the APEX technique, and 72 patients received standard DIEP flap breast reconstruction. <b>Results</b>: Our study demonstrated a statistically significant increase in operative time, averaging 30.5 min in the APEX group (<i>p</i> < 0.05). There was also a significant difference in the incidence of marginal flap necrosis between the two groups. No cases of myotomy were observed, and motor nerve transection was required in one case. <b>Conclusions</b>: The APEX technique has been shown to be reliable when standard dissection would compromise the neuromuscular anatomy of the abdominal wall without compromising perfusion in the flap.