DIEP Flap

Once reconstruction is completed, no maintenance is required. Occasionally nipple/ areolar tattoos will need “freshening,” but that’s optional.

Women that have had a previous TRAM flap, tummy tuck or very extensive abdominal wall surgeries (like complex repairs of huge hernias) cannot have a DIEP or SIEA flap reconstruction because the lower tummy tissue that is needed has already been removed, disconnected or moved around.

Having said that, most of the time previous abdominal surgery really isn't an issue.

Many women these days have had a previous c-section or hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery but this is rare. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having the procedure.

If your surgeon is worried about potential damage from previous surgery then certain tests can be performed to examine the anatomy more closely. This can include a simple doppler ultrasound exam in the office or a more involved test like a CT angiogram.

While previous abdominal surgeries may not prevent DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and even hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery.

Some medical issues can make any form of microsurgical breast reconstruction (including the DIEP flap) more difficult and also increase the risk of complications like flap loss. These include disorders that make the blood clot more easily (eg Factor V Leiden).

I hope this info helps.

Dr C
http://www.PRMA-enhance.com

That depends on what you mean by “not healing quickly.” If you have an unhealed wound, then something is really wrong, and you should see your surgeon. If it simply hurts or “doesn’t feel right,” then it may improve with time, or you may be developing capsular contracture (a common problem with implants), which may not go away. If you still want a flap, you may well still be able to have one from your buttock or elsewhere.

Richard M. Kline Jr., M.D.

Depending on the specifics of your situation, you may still be a good candidate for another type of flap, or for a tissue expander. If you feel more comfortable getting a second opinion, then I'm sure your original plastic surgeon will understand. Because of the complexity of your case, if you do see another plastic surgeon it would be best if it is someone with significant experience in breast reconstruction, either here in the NYC metro area, or closer to your home if you prefer and can locate someone with the appropriate experience.

My mother was diagnosed with breast cancer 23 years ago. My father, a General Surgeon, recommended a mastectomy. My mother was very active and particularly enjoyed water sports. She did not want to lose her breast, and if that were necessary, would desire reconstruction. I was put in charge of the breast reconstruction and planned a possible pedicle TRAM flap procedure knowing my mother would miss the function of her rectus abdominus muscle. Fortunately margins were clear on re-excision of the cancer and she was treated with lumpectomy and radiation. After this I was determined to develop better options for breast reconstruction. By studying the blood supply to the skin and fat of the lower abdomen, I discovered how to reliably transfer only the skin and fat without muscle sacrifice using microsurgical technique. Thus was born the whole field of Perforator flaps for breast reconstruction starting with the DIEP flap.

A Plastic Surgeon moves tissue around to restore form and function. Using microsurgical technique allows us to move tissue from anywhere to anywhere in the body creating more options to choose from for a particular patient. Microsurgical transfer of tissue for breast reconstruction has the highest success rate over any other method. Traditionally the drawback of this technique is that it requires specialized training in microsurgery. Special equipment is needed, and the length of the procedure may be longer than other methods. By specializing in microsurgical breast reconstruction, I have greatly reduced the OR time, decreased the complication rate, and increased success rate. Success rate with DIEP breast reconstruction is over 99%. These advances make the patient’s decision to select this procedure with the most natural, permanent result easier.

By far the best result and state of the art today involves Nipple Sparing Mastectomy(NSM) and immediate reconstruction with DIEP or other Perforator flaps. For an optimal outcome, it is crucial to have a breast surgeon well trained in NSM and the right plastic surgeon. Ideally a one stage mastectomy and reconstruction can be done. Typically the breast would have a faint scar on the under surface of the breast. The DIEP donor site should be the same as a cosmetic tummy tuck. If the abdomen is not a good option, skin and fat can be obtained from the posterior thigh leaving a scar concealed in the fold beneath the buttock. This is my most recent innovation and is called the PAP flap.

The sensory nerves to the nipple arise from the intercostal nerves coming off the spinal cord traveling on the under surface of the ribs. They give off posterior branches in the axilla and anterior branches just lateral to the sternum. We often dissect the 4th and/or 5th posterior intercostal nerves for 5 to 7 centimeters at the time of mastectomy. A sensory nerve on the DIEP flap can be connected to the breast nipple nerve to restore sensation to the new breast. Also the anterior branch can be coapted to the DIEP sensory nerve. Even without a nerve repair, the sensory nerves slowly grow into the DIEP flap resulting in some sensation in most patients over 12-24 months.

Most of my patients today have nipple sparing mastectomies. It is very important for the Breast Oncologic Surgeon to spare the medial intercostal nerves and blood vessels during the mastectomy. The most important one arises between the 2nd and 3rd rib cartilage just medial to the breast tissue being removed and just lateral to the sternum. This allows for better return of nipple sensation.

Sincerely,
Bob Allen,MD

The ideal tissue for breast reconstruction lies transversely across the lower abdomen. The quality and permanence of autogenous breast reconstruction is far superior to implant reconstruction. My goal was to discover the best donor site with the least risk to the patient. The TRAM flap of the early 1980’s was able to make a natural breast without implants, but the abdomen suffered from sacrifice of the rectus abdominus muscles. In 1989 I began investigating the blood supply to the lower abdominal skin and fat. I first concentrated on the superficial inferior epigastric blood vessels. By injecting the superficial inferior epigastric artery(SIEA) on fresh abdominoplasty specimens, I concluded that the skin and fat of the lower abdomen could be transferred using microsurgical techniques to reconstruct a breast without sacrifice of the abdominal muscles. The first cases went great, but I realized some patients either did not have a superficial artery or it was too small. I briefly abandoned the SIEA procedure and began doing free TRAM flaps. Unfortunately the free TRAM resulted in hernias, weakness, and pain. I re-examined the blood supply of the lower abdomen concentrating on the deep inferior epigastric system. By injecting a single dominant perforator of the deep inferior epigastric artery, I demonstrated that this could be used to transfer the lower abdominal skin and fat. Thus was born the DIEP flap for breast reconstruction in August 1992 at Charity Hospital in New Orleans.

As Director and later Chief of the Plastic Surgery Residency Program at Louisiana State University Medical Center until Hurricane Katrina in 2005, I trained one or two Fellows a year in Microsurgical Bresast Reconstruction. Since then I have trained 12 Fellows at the Medical University of South Carolina and New York University Medical Center.

Sincerely,
Bob Allen,MD

Lymphedema in the breast cancer patient is caused by removal of axillary lymph nodes with subsequent inflammation and scar formation in the axilla. Radiation therapy further increases the chance of lymphedema. DIEP flap breast reconstruction does not result in more scarring in the axilla and should not cause or aggravate lympedema. With approximately 2000 DIEP breast reconstructions over the past 20 years, no patient has developed lymphedema as a side effect of this surgery.

In 2003 I began vascularized lymph node transfer to the axilla to reduce or eliminate lymphedema. In 2006 I combined the DIEP flap with lymph nodes the restore form and function by reconstructing the breast and treating the lymphedema in one operation. At an international microsurgery symposium I met Corinne Becker, MD. She has been successfully treating lymphedema with vascularized lymph node transfer for many years and is the world leader in this area.

The lady who posed the question is a candidate for combined DIEP/lymphnode transfer to restore both form and function.

Sincerely,
Bob Allen,MD

I had diep flap reconstruction on 11/15. Unfortunately flap on rt side failed, so I have an implant on the rt and the flap on the left. I like the appearance and the feel of the flap versus the implant. The implant has really been causing a lot of trouble for me, and I may just have it taken out.. Make sure you really do your homework on this. It was a grueling 15 hour surgery for me. I also needed a blood transfusion after.

I don't regret my choice, but it is a little disappointing to go through all of that and not have optimal results. Good luck with everything.

Specifics may vary from case to case and practice to practice, but all failures involve interruption of the blood supply. This can be caused from a clot forming at the arterial or venous anastomosis, or from a conformational change in the blood vessel which produces “kinking” and subsequent interruption of blood supply. Most surgical teams experience dramatically lower failure rates as their experience expands, and it can get very difficult to determine precise reasons for failure (and ways to prevent it) when failure is a very rare event, i.e., success rates of 98-99%, which is typical for experienced surgeons. The best teams will nonetheless strive, whenever they have a failure, to find some “take home message” which they can use to hopefully further minimize their failure rate.

Richard M. Kline Jr., M.D.

In our experience, no, although in a large enough series it may. We have always been able to use the internal mammary vessels, supplied through collaterals, to successfully supply blood to a second flap after an initial flap failed. Generally speaking, the collateral supply to the internal mammary from one intercostal artery is probably sufficient to supply a new flap. I do think that it is advisable, however, to wait at least 3 months following an initial flap failure before attempting a second flap, as this gives time for tissue edema to resolve, and serum protein levels to return to normal.

Richard M. Kline Jr., M.D.

I am about 4 weeks post op today. I went out on 11/13 and will return to work on 1/23. I'm a nurse and I work in a busy psych clinic. I was active and in good health prior to surgery, but there is no way I could return to work yet. I believe that I will need the full ten weeks to recover.

There is a big psychological component that needs to be processed during this time. It is a time to be gentle with yourself, I believe it is important to give yourself enough time to heal both physically, and emotionally.

I had a diep flap done on 11/15. Double mastecomies with reconstruction lasted 15 hours. Unfortunately, the flap on my rt side failed, so a decision was made to place an implant on the rt side. I like the look of the flap, and the feel. The flap feels more natural...the implant feels numb and tight.

The surgery was no joke, very intense. I was in the hospital for five days, and needed a lot of help for about ten days beyond hospitalization. I came home with 5 drains. I also needed a blood transfusion.

Make sure you consult with more than one plastic surgeon. Make sure you also have a plan B...what will be done if the flap fails. I don't have regrets about my choice, but I do wish I had 100% success.

The main advantage of the perforator flap over the transverse rectus abdominis (TRAM) flap is the reduction in donor site complications such as abdominal wall herniation and weakness. Nevertheless, there is still some risk of abdominal wall hernia. This is reported to be 0.7% according to Spear.

The other main long term complication of the DIEP flap is fat necrosis (12.9%) which can often be felt as a mass in the reconstructed breast.

Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years!!

Absolutely.

We commonly perform DIEP flap reconstruction in patients that have undergone radiation as part of their breast cancer treatment.

It is very rare for the internal mammary vessels to be damaged to the point where they are not usable.

In the rare event that they are too damaged, there are other vessels we can use in the chest or armpit.

I hope that helps.

Dr C
http://www.PRMA-enhance.com

ps. Congratulations on the 2 years!