Who is NOT a DIEP flap candidate?

With more women becoming aware of DIEP flap breast reconstruction as an option, the question of who is and who isn't a good DIEP flap candidate is coming up more often.

As a general rule, women that have had extensive abdominal surgery like a previous TRAM flap, tummy tuck or a complex hernia repair cannot have a DIEP or SIEA flap breast reconstruction. This is because the lower tummy tissue that is needed has usually been removed or moved around, and the necessary blood supply has been disrupted.

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

Many women these days have had at least one previous c-section or another gynecologic procedure like a hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery but fortunately this is unusual. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having a DIEP or SIEA flap. Previous liposuction is not usually a problem either unless this was extensive.

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

While previous abdominal surgeries may not prevent you having DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery, even though the abdominal muscles are preserved. This is because the fascia (the strong layer of tissue over the muscles) has already been weakened by the previous surgeries.

Some medical issues can make any form of microsurgical breast reconstruction (like the DIEP flap) more difficult and they can 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

*****

Dr Chrysopoulo is a board certified plastic surgeon in San Antonio, Texas specializing in state-of-the-art reconstructive breast surgery. He and his partners at PRMA are In-Network for most major US insurance plans. Patients are welcomed from across and outside the US. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer patients on Facebook.

*****

Abdominal Muscle - Why Save It?

Most women that have looked into breast reconstruction know about the TRAM flap. The TRAM uses lower abdominal skin, fat, and varying amounts of abdominal muscle to reconstruct a "natural", warm, soft breast after mastectomy. The TRAM used to be the gold standard in breast reconstruction, but not anymore.

Over the years, the TRAM flap procedure has evolved into two more advanced procedures that decrease the risk of abdominal complications: the DIEP flap and the SIEA flap. Both use the same lower tummy skin and fat but unlike the TRAM, both SAVE all the abdominal muscle and leave it in place.

The SIEA flap differs from the DIEP flap only in terms of the blood vessels that supply the tissue. While the surgical preparation is slightly different, both procedures spare the abdominal muscle completely and only use the patient's skin and fat to reconstruct the breast. 

All three procedures provide the added benefit of a flatter abdomen with results that mimic a “tummy tuck”. However, because the TRAM flap sacrifices abdominal muscle, the risk of a hernia or abdominal bulging is signifantly higher than with the DIEP or SIEA procedures.

Since the DIEP and SIEA flaps preserve all the abdominal muscles, patients experience less pain than after TRAM flap surgery, enjoy a faster recovery and also maintain their abdominal strength long-term.

I hope this info helps.

Dr C

*****

PRMA Plastic Surgery specializes in advanced breast reconstruction including DIEP flap, SIEA flap, GAP flap, TUG flap, Alloderm One-Step and fat grafting. In-Network for most US insurance plans. Patients routinely welcomed from across the USA. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery.

*****

Breast Reconstruction With Tummy Tissue (Abdominal Flaps)

DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it's difficult to understand what these terms really mean and what the differences are between all these "tummy flap" procedures.

It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.

Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient's own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: TRAM flap, DIEP flap, or SIEA flap.

The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap ("pedicle", "free", and "muscle-sparing free"): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20% or more), bulging (or "pooching"), and even abdominal hernia.

The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The “SIEA” blood vessels are generally found in the fatty tissue just below skin whereas the “DIEP” blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging). Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery.

Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20% of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.

Since the TRAM, DIEP and SIEA procedures all use the patient's lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.

There are many plastic surgeons in the US offering TRAM flap reconstruction. Unfortunately, very few centers in the US routinely perform the advanced microsurgical procedures like the DIEP and SIEA flap. Many patients will therefore have to travel for these procedures.

When considering a reconstructive surgeon, ensure he/she is a plastic surgeon certified by the American Board of Plastic Surgery that has extensive experience with this specific type of surgery. Also ask about the success rate in their hands - most specialists boast a flap survival rate of 97% to 99%+.

The 2 websites below list surgeons that offer DIEP and SIEA flap reconstruction and serve as a good starting point when researching surgeons:

www.diepbreastreconstruction.org and www.breastrecon.com

*****

Dr Chrysopoulo is a board certified plastic surgeon at PRMA Plastic Surgery. PRMA specializes in microsurgical breast reconstruction including the DIEP flap procedure. PRMA has performed thousands of DIEP flaps and is In-Network for most US insurance plans. On Facebook?.... Connect with other breast cancer patients in our FB Breast Cancer Reconstruction Community.

*****

Are you a DIEP Flap candidate?

The DIEP flap procedure has rapidly become the "gold standard" in breast reconstruction today. While not every woman is a candidate for DIEP flap surgery, many are turned away when in fact they needn't be. The most common areas of confusion include:


1) Previous Abdominal Surgery

While some types of previous abdominal surgery can make the DIEP flap procedure impossible to perform, 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.

So which previous surgeries DO cause a problem? 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.

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.


2) An Umbilical Hernia

It is very unlikely that an umbilical hernia would prevent DIEP flap surgery. Most umbilical hernias are small. A very large umbilical hernia can make the surgery harder but even this is not usually a contra-indication to having the procedure.


3) Previous Chest Radiation

One of the most important things for the reconstructive surgeon to achieve is to replace the damaged, firm irradiated tissue with normal, healthy, soft tissue. If the irradiated tissue is not healthy enough to be used as part of the reconstruction (as is the case in many instances), it will be removed and replaced by the healthy (DIEP) tissue.

I have visited with a fair number of patients who have previously been told they are not candidates for DIEP flap reconstruction because they received chest radiation after their mastectomy. I do not share this opinion.

Most of the time this advice seems to stem from fear that the radiation may have caused damage to the internal mammary vessels in the chest. These are the blood vessels that are usually used to connect the DIEP flap to the chest. In reality it is exceptionally rare for us to find these blood vessels are damaged and cannot be used.


4) Not the Right Amount of Tissue

You don't need to be overweight to be a candidate for a DIEP flap. What matters is the distribution of the fat. We have performed DIEP flaps on smaller breast, thin women with a BMI (body mass index) of 20 (and even less) because the fat that they did have was "in all the right places". Having said that, there is an upper limit beyond which the risks of surgery outweigh the benefits - At PRMA we set an upper BMI limit of 40 as we have found that performing the procedure on women with BMIs greater than this significantly increases the rates of complications (especially wound healing problems).



*****

Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques . He and his partners are in-network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

*****