DIEP Flap Reconstruction

Breast reconstruction is a relatively common procedure in the United States. Women across the country visit plastic surgeons with the desire to restore the breast or improving their breast after a cancer surgery. While there are many procedures that physicians utilize for breast reconstruction, one of the most effective procedures is the DIEP flap.

PROCEDURE OVERVIEW

A DIEP flap is a procedure that reconstructs the breast using the patient’s own abdominal tissue and is most commonly done after a mastectomy. The procedure involves taking skin and fat from the tummy with a blood supply. The skin and fat is transplanted to the chest while the blood vessels are connected to recipient blood vessels in the chest. This procedure provides a total breast reconstruction with just skin and fat from the tummy. It is a good alternative to other options for breast reconstruction.

STACKED DIEPS

Stacked DIEPs is when bilateral DIEPs are done for one breast and stacked on top of each other for more projection and volume. More commonly one side of the abdomen is used for one breast.  For a unilateral breast reconstruction, a specialized plastic surgeon can take both sides of the tummy, which means two separate blood supplies and the entire area of skin and fat from the tummy, to provide increased volume to a single breast. When the tissue is placed side to side it is termed a double DIEP but when stacked for further projection it is termed a stacked DIEP.

DIEP VS TRAM

When comparing DIEP flap to TRAM flap reconstruction, they are both similar in the sense of where the tissue comes from and how it appears in the breast. The major difference is TRAM stands for transverse rectus abdominis myocutaneous flap while DIEP stands for deep inferior epigastric perforator flap.

In a TRAM procedure, the muscles are actually removed so the patient’s six-pack muscles are taken up to the breast. The DIEP flap does not remove muscle. That is a huge advantage for the patient in the sense that the abdomen does better post operation. The hernia rate, bulge rate, and pain are greatly decreased with the DIEP flap in comparison to the TRAM flap. With bilateral TRAM flaps, a patient can have other problems including decreased core strength.

COST

The total cost of reconstructive breast surgery varies across the United States. It is fairly expensive when everything is added into the final cost. Most doctors that do DIEP flaps put their patients in the ICU for a couple of nights. It is not that the patients are sick they just need to stay in a monitored area to check the blood flow of that tissue, which adds to the cost. Additionally, it can be a long operation (four to twelve hours), which ultimately adds to the cost.

MISCONCEPTIONS

Many people do not realize that a plastic surgeon is actually hooking up the blood vessels during a DIEP flap reconstruction. It is actually a very delicate operation involving a microscope and connecting blood vessels that can be anywhere from 2-mm to 3 ½-mm in size. It takes a significant amount of work and a special skill set. Every step is crucial for the surgery to come out well and it has to be done carefully. It is a highly specialized surgery that not all plastic surgeons offer.

ADVANTAGES

The biggest advantage of the DIEP flap as opposed to the TRAM flap is that it does not remove the muscle so there is less damage to the tummy and ultimately a better result.  This leads to lower hernia and bulge rates in the tummy.  The actual raising of the flap, and preserving of the muscle, is much more challenging in the DIEP flap than the TRAM flap. Overall, it is all about preserving the abdominal musculature.  In comparison to other options for breast reconstruction (implant based) this tissue offers a natural reconstruction that will last forever.

NON-IDEAL CANDIDATES

If a patient does not have enough perforators to use in order to supply the DIEP flap, the procedure is not recommended. This could include patients that have had a tummy tuck or other abdominal surgery. Additionally some patients are very thin and lack enough tissue in their tummy. In these situations the surgeon can consider alternative flap options. Additionally, the patient must be healthy enough to withstand a relatively long surgery.

SIDE EFFECTS

The short-term DIEP flap reconstruction side effects include the abdomen being uncomfortable for a period following the procedure. There can be abdominal wounds, which typically heal without sequela. Additionally, a bulge can happen in a DIEP flap but it is very uncommon. A bulge would have to be a unique situation where the muscle is damaged because the blood vessels (the course of the actual blood vessels for a specific patient) caused the dissection to damage some muscle. There is also a chance of failure in the connection of the blood vessels. In experienced hands this is not common but is always a potential risk.

NOT AVAILABLE EVERYWHERE

DIEP flap reconstruction is a more advanced version of TRAM so not all plastic surgeons perform it. The DIEP flap is performed at most major medical centers but will not be offered by most plastic surgeons. There are alternative flaps that are further specialized and offered at fewer places.

RESULTS

A patient sees an immediate result following a DIEP flap reconstruction. The patient will be swollen following the surgery, which will go down in the months following surgery. The patient will not get a good idea of the final results for at least a few months if not longer. Within approximately a year the scars will fade significantly. The reconstruction continues to evolve over that time period. Either way the patients do wake up and have a natural breast reconstruction immediately after surgery.

FINAL THOUGHTS

DIEP flap reconstruction has many advantages over the TRAM flap. It is vital that a patient has an experienced surgeon handling the procedure. Before undergoing DIEP flap reconstruction, it is important for a patient to research their surgeon of choice. Making sure the doctor is skilled in DIEP flap reconstruction techniques is an important step before the patient moves forward with scheduling, and undergoing the procedure.

Written by Cosmetic Town Editorial Team- MA

Based on an exclusive interview with Dr. Nicholas Haddock in Dallas, TX