DIEP Flap Reconstruction Austin
Perforator flaps represent the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from another part of the body. Tissue flaps are typically performed at the same time as a mastectomy (immediate) or are an option for women that have already had a mastectomy (delayed). Perforator flaps should only be performed by Plastic Surgeons who are specifically trained in microsurgery. There are very few surgeons who are capable of performing this type of reconstruction. Dr. Snyder and Dr. Whitfield at the Breast & Body Center of Austin both completed fellowships in microvascular surgery. Dr. Snyder and Dr. Whitfield are two of the pioneers in this technique and have collectively performed thousands of perforator breast flap reconstructions.
One such flap is a DIEP (Deep Inferior Epigastric Perforator) flap. In a DIEP, an incision along the bikini line is made much like that used for a tummy tuck. The necessary skin, soft tissue, and tiny feeding blood vessels are removed. These tiny blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope.
Unlike conventional TRAM flap reconstructions, a DIEP flap allows for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast the contour of the abdomen is often improved much like a tummy tuck.
Recreation of the nipple and areola in follow subsequent procedures. Scars fade substantially with time. For many women, the reconstructed breast may be firmer and have a more youthful appearance than their natural breasts. The main benefit of a flap reconstruction is, given that you are using your own tissue, the resulting reconstructed breasts look and feel natural.
DIEP flap breast reconstruction results in the creation of a “natural” breast without muscle removal. One in nine women develops breast cancer with some requiring mastectomy for treatment. Psychological and emotional benefits associated with breast reconstruction are huge.
With the Deep Inferior Epigastric Perforator no muscle is removed. The perforating vessels with the overlying flesh are removed and the muscle is left in place. Patients recover quickly with usually only a three-day hospital stay. The abdominal scar is placed low on the abdomen because no muscle is removed. The perforator blood vessel dissection increases operating time but the body tolerates superficial surgery well.
FREQUENTLY ASKED QUESTIONS ABOUT DIEP FLAP RECONSTRUCTION
What is DIEP flap breast reconstruction?
DIEP flap breast reconstruction surgery is a procedure that involves taking skin and fat from the abdomen, along with the corresponding blood vessels, and transplanting this tissue to create breasts. This procedure is for women who have lost their breasts due to mastectomy or other reasons.
Why is it called a free flap?
It is considered a free flap procedure because the abdominal tissue is freely separated from the body and reconnected under a microscope, establishing a new blood supply. The tissue is then surgically fashioned into new breasts.
Does this procedure require the removal of my abdominal muscle?
DIEP flap reconstruction is unique because it does not use any muscle. The rectus abdominus remains intact which allows for patients to still use full strength of the muscle.
Are there specific tests required prior to procedure?
At the time of your pre-op appointment you will be sent with orders for a CTA (“CAT Scan”) of the abdomen. A CTA is an image that is used to view suitable blood vessels in preparation for the procedure. The images will help map out the blood supply to the abdominal wall and to decide which of the blood supply will be used. An radiology appointment will need to be made in advance to schedule the study.
Why does blood supply need to be dissected?
The new breast will need blood supply to survive. The blood supply to this skin is within the muscle beneath. A portion of this blood supply is removed from the abdominal muscles. The abdominal blood vessels used are connected to vessels at the mastectomy site. The small blood vessels are carefully reattached under a microscope.
Where is the incision site for the removal of a flap?
The incision is usually along the bikini line. The incision site is similar to a tummy tuck (abdominoplasty) allowing for the abdomen to be contoured. The incision is usually hidden under normal clothing. The length of the incision is from hip to hip along the lower abdomen.
How long is the procedure?
Usual length of a Unilateral DIEP breast reconstruction ranges from 2-3 hours in length. Bilateral DIEP breast reconstructions range from 4-6 hours in length. Additional time is needed when combined with the mastectomy. Your family will be given a report on the progress periodically.
I have a port in place. Can it be used?
Ports for chemotherapy may be used during and after surgery.
Will I be admitted into the hospital?
Admission into the hospital following reconstruction is appropriate and necessary. Expect to be admitted into IMC (Intermediate Care Unit) or ICU (Intensive Care Unit) for a total of 3-5 days following the procedure. The reason for being admitted into IMC/ICU is because they are the only units capable of checking the breast flaps hourly. On a regular floor at the hospital, the staff is not given the opportunity to give the demanding care that is needed. Checking the flaps hourly allows us to monitor the progress and survival of the flaps. Small sensors on your breasts connected to a bedside console and are used to continuously ensure the flap has adequate blood flow.
Before you are discharged you will need to perform activities such as sitting up, walking, eating, and moving your bowels.
What will happen to my belly button?
You will actually keep your own belly button. Since abdominal skin will be excised from the low part of your abdomen, making it necessary to relocate the belly button.
Will I have a nipple?
After your initial DIEP breast reconstruction surgery, you will typically not have a nipple. After healing from your original breast reconstruction, you will be a candidate for nipple reconstruction. Nipple reconstruction may be performed as an office procedure. Patients are measured for symmetry and a small portion of skin from your new breasts is used to create a nipple. Some patients opt to undergo 3 dimensional nipple areola tattooing. These tattoos give the illusion of a nipple but have no actual projection. The tattooing is also offered as a procedure in our office, and is typically covered by insurance.
What prescriptions are given to control pain?
During surgery, we use a long acting anesthetic that is diffused directly into your tissues. Most patients have very little pain immediately after surgery. You will also be given pain medication through your IV after surgery. During your hospital stay, you will be switched to pain medication given by mouth. There are many options we can use for pain control. This will be discussed in further detail if desired. It is important to inform the physician if you have any drug allergies.
Will I need to discontinue the use of Tamoxifen?
In preparation for surgery it is important to stop all hormone treatments. Drugs including Tamoxifen and Arimidex have a common side effect that may cause blood clotting. To reassure the procedure is successful please discontinue the use of these medications 1 month prior to procedure if possible.
Will I have drains?
Drains are placed during the surgery to avoid fluid accumulation underneath skin and tissue. Drains will be located on each side of the abdominal incision site and at least one additional drain is placed at each breast. After discharge, it is important to record the amount of drainage that is emptied from the bulb. The amount of drainage is important because it helps determine when the drains are ready for removal.
The drainage will be dark red in color at first. As you start to heal the drainage may be a lighter red then eventually turn yellow or brown in color. Drains are usually ready for removal after they produce less than 30cc in a 24 hour period. An estimated time for drains to stay in place is 1-3 weeks. Please see our handout on “Taking Care of Your Drains” for further information on drain care.
What is the recovery period?
Recovery periods vary for each patient. Typically, you are sore and tire easily for the first few weeks after surgery. After two weeks, you will notice an increase in energy levels each day. Generally, heavy lifting or strenuous activity should be avoided for at least 4-6 weeks after the procedure. You will need to consult the physician for clearance to begin exercising, traveling, etc..
Is smoking ok?
You will not be a candidate for procedure if you use tobacco in any form, including patches, pills, and gums. It is extremely important that you refrain from smoking or using any nicotine products (including patches, pills, gums, and e-cigs) for at least 6 weeks prior to surgery. Smoking can dramatically impair wound healing and complicate your post-op care.