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

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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.

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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).



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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!

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