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Today, breast cancer survivors have a variety of breast reconstruction
options.
Most select saline or silicone gel implants, which offer simplicity and good
aesthetic results. However, many patients say the result never feels natural;
they are always aware of something sitting under their chest muscles. Consequently,
many opt for breast reconstruction surgery. Indeed, about a quarter of the women
who undergo breast reconstruction have already tried implant reconstruction. |
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When the TRAM (transverse rectus abdominal myocutaneous) flap was developed
in the early 1980's, it ushered in a new era of reconstruction and
women were thrilled with the opportunity it presented. Over time, though,
it became clear that the procedure was less than gentle on the donor site
and resulted in abdominal hernias and weak stomach muscles.
About ten years ago, plastic surgeons developed the DIEP (deep inferior
epigastric perforator) flaps, which transfers the patient's own skin and
fat to the chest area. This technique is gentler on the donor site and makes
it easier to appropriately match donor and recipient sites. It is a good
option for most women seeking reconstruction and has withstood the test of
time for a decade.
The DIEP flap uses a woman's
own lower abdomen to provide soft tissue for the chest area. It carries the
same quality of tissue as the TRAM flap procedure without harming the muscle
and fascia. As a result, it minimizes donor site morbidity and pain and shortens
recovery time. DIEP flap reconstruction also works well for women requiring
additional breast tissue for congenital deficiencies or lumpectomy defects.
In our practice, we have found the DIEP procedure appropriate for most women
requiring breast reconstruction surgery. However, we do not perform the procedure
on women with a history of abdominoplasty or abdominal liposuction or women
who have smoked as recently as one month prior to surgery. We carefully evaluate
the procedure's appropriateness for women with large transverse or
oblique abdominal incisions.
Plastic Surgeons prefer to have women wait until six months after and radiation
therapy before placement of the free flap. While the perforator flaps usually
tolerate radiation well, we find that we achieve the best long-term result
when we perform the reconstruction after, rather than before, chest wall
radiation. This approach also allows surgeons to remove any thick and stiff
irradiated chest wall skin and replace it with soft and unradiated abdominal
skin and soft tissue.
The DIEP flap is based on the deep inferior epigastric artery and
vein. Two rows of perforating arteries and veins penetrate the rectus muscle
on each side of the abdomen to provide the blood supply for the overlying
skin and fat. The deep inferior epigastric artery is typically between 2mm
and 3mm in diameter and the accompanying veins generally measure 2mm to 3.5mm.
Surgeons performing the DIEP flap procedure follow the perforating vessels,
which supply blood to the overlying skin and fat, through the rectus muscle
to their origins from the deep inferior epigastric vessels. This process
spares the rectus muscle itself and separates it atraumatically in the direction
of the muscle fibers.
Typically, plastic surgeries see their patients in
the office the day before surgery for preoperative markings, Doppler studies,
and to review the surgical plan. The surgeons make abdominoplasty markings
on the side of the abdomen contralateral to the side to be reconstructed,
which facilitates insetting during surgery. Women sit or stand while surgeons
mark the flaps at approximately 12cm high at the midline, extending the line
about 22cm to 24cm across.
Then, the woman lies down and the surgeon uses a Doppler probe to identify
the main perforators of the medial and lateral branches of the deep inferior
epigastric artery and the superficial inferior or epigastric artery and vein.
Doctors mark these arteries and veins also.
Most plastic surgeons simultaneously raise the DIEP flap and prepare the
recipient vessels, selecting vessels with similar diameters. They almost
always find that the internal mammary artery and vein are the most appropriate
recipient vessels both because of their diameter and their location in the
chest wall, which facilitates medial insertion of the flap. Plastic surgeons
dissect the vessels in the second or third intercoastal space, usually working
in a field measuring 2cm to 3cm wide. If the rib space is less than 3cm in
width, surgeons sometimes remove a portion of the lower rib to more easily
orient the vessel.
Next, the surgeon carefully elevates the abdominal skin from lateral to
medial until she can inspect the lateral row of perforators. If she finds
a large lateral perforator, she may base the flap on this vessel, using additional
perforators in the same row as needed. In our practice, we prefer to use
a single large perforator if possible because it carries more blood flow
and is associated with less fat necrosis than several smaller perforators.
In the case of a unilateral DIEP flap reconstruction, surgeons might also
consider using the perforators on the opposite side of the abdomen.
Once the surgeon has selected the most appropriate perforators, she opens
up the anterior rectus sheath and dissects the vessels down through the rectus
muscle to the deep inferior epigastric artery and vein. She spreads the muscle
apart in the direction of the fibers, taking care to identify and preserve
and intercoastal nerves innervating the medial aspect of the muscle that
might cross the pedicle.
When the surgeon prepares the recipient vessels at their origin, she marks
the anterior surface with a surgical marker for vessel orientation in the
chest to prevent kinking or twisting. She ties the artery and veins of the
pedicle and slides it under any crossing intercoastal nerves. Then the surgeon
weighs the flap and transfers it to the recipient site, careful not to create
any new twists or kinks in the vessels.
Using the operating microscope, the surgeon labels the anterior surface
of the recipient artery and vein. She connects the recipient and flap veins
with an attachment coupling device, which makes the process easier and faster
and also helps the vein stay open.
The plastic surgeon closes the donor site either during the micro-anastomosis
or while inserting the flap, using running absorbable sutures rather than
mesh or another synthetic material. She elevates the upper abdominal flap
so that the wound closes in layers over the two closed suction drains. The
surgeon brings out the umbilicus through the abdominal flap and secures it.
Plastic surgeons perform the insetting and closure over a suction drain
in order to continuously monitor the integrity of the pedicle. If surgeons
use a contralateral flap, they generally turn the flap down at approximately
90° to 120° so that the medial portion of the abdominal flap becomes
the base of the reconstructed breast and the apex of the triangular flap
becomes the “tail.” Surgeons stabilize the lateral portion of
fat flap to the lateral aspect of the pectoralis major muscle with absorbable
sutures to keep the flap from falling out into the axilla and creating additional
tension on the anastomosis.
Next, surgeons removc any excess skin both superiorly and inferiorly and
inset the flap leaving a visible skin paddle place. This skin paddle makes
it easier to monitor for venous congestion after the surgery. Surgeons use
the external Doppler probe to identify good arterial and venous signals on
the flap and they mark these locations for postoperative monitoring. Some
surgeons implant a Doppler probe on the vein and/or artery to facilitate
postoperative monitoring, especially when there is little or no skin paddle
left.
Most patients spend the night of their operation in the surgical intensive
care unit for observation. Typically, they move to the main hospital floor
the following morning and begin oral pain medications. Most patients can
walk on the first day after surgery and leave the hospital no later than
four days after surgery.
Complications of DIEP flap surgery are infrequent. We studied more than
750 DIEP flap reconstructions and found that only 6% of patients returned
to the operating room for flap-related problems. DIEP also minimizes long-term
problems. Fat necrosis and seroma formation at the abdominal donor site occurred
in approximately 5% of cases and abdominal hernia occurred in 0.7% of cases,
which is less frequent than with the TRAM flap procedure.
As a result, perforator flaps have raised the standard in breast reconstruction.
The DIEP flap is an excellent and safe choice for breast reconstruction and
is becoming increasingly popular. Over the past 10 years, DIEP flap surgery
has been shown to be safe, reliable, and esthetically superior in the long
term. And more women are enjoying the results.
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