Cosmetic Surgery Tips

Breast Reconstruction Deep Inferior Epigastric Perforator

Breast reconstruction is a surgical procedure that restores the shape and size of the breast after breast cancer surgery. Deep inferior epigastric perforator (DIEP) flap breast reconstruction is a type of surgery that uses tissue from inside your body to create your new breast. The DIEP flap is made up of fat, skin and blood vessels. The DIEP flap is one of several options available when choosing how to do breast reconstruction surgery.

There are different types of DIEP flaps, including pure and composite flaps. A pure flap has no muscle or nerves in it; a composite flap has both fat and muscle in it. A pure flap is more likely to have problems with scarring than a composite flap because there are no muscles in it for support. A pure DIEP flap is also more likely to have problems with the blood supply than a composite flap because it does not have any muscle tissue to help keep blood flowing through it.

This article also talk about deep inferior epigastric perforator flap and deep inferior epigastric artery origin.

Breast Reconstruction Deep Inferior Epigastric Perforator

Deep Inferior Epigastric Perforator Flap

In deep inferior epigastric perforator (DIEP) flap breast reconstruction, Massachusetts General Hospital Division of Plastic and Reconstructive surgeons use skin and fat from the lower abdomen to create a new breast after mastectomy.

About the Procedure

If you have a mastectomy to treat or prevent cancer, breast reconstruction can surgically recreate a natural-looking breast. One option for breast reconstruction is a deep inferior epigastric perforator (DIEP) flap procedure.

In a DIEP flap, the surgeon first excises skin and fat from the lower abdomen. This process does not require removing any of the rectus abdominus muscle, which houses the artery and vein that serve as the primary blood supply to skin and fat of the lower abdomen.

The excised abdominal tissue, or “flap,” is then transferred to the mastectomy area. There, blood flow is restored by reconnecting the artery and vein to a set of vessels in the chest wall. The surgeon then shapes the flap to form a new breast.

Unlike the TRAM flap, the DIEP flap avoids using abdominal muscle. DIEP flaps thus take longer to complete. However, they may involve less postoperative pain and may reduce the risk of hernia formation.

Please note: A DIEP flap leaves a scar that extends along the lower abdomen, from one hip to the other. As a result, the recovery period may be longer than with breast construction with implants or tissue expanders.

Breast Reconstruction at Massachusetts General Hospital

Our plastic surgeons have extensive experience in all types of breast reconstructive techniques, including the newest and most innovative procedures. When appropriate, we combine techniques, using flaps, implants and nipple tattooing to achieve the most natural-looking outcome.

All forms of breast reconstruction after mastectomy have inherent risks, which will be fully discussed during your consultation.

Qualities of Candidates

You may be a good candidate for DIEP flap reconstruction if you:

  • Are not a candidate for implant reconstruction
  • Have had failed reconstruction using a breast implant
  • Have had radiation administered to your chest wall
  • Have sufficient tissues in your lower abdomen to create one or both breasts
  • Have never had surgery on your abdomen
  • Prefer to reconstruct one or both breasts using your own tissue

You may not be a good candidate for DIEP flap reconstruction if you:

  • Are not a candidate for implant reconstruction
  • Have had failed reconstruction using a breast implant
  • Have had radiation administered to your chest wall
  • Have sufficient tissues in your lower abdomen to create one or both breasts
  • Have never had surgery on your abdomen
  • Prefer to reconstruct one or both breasts using your own tissue

Other Reconstruction Options

Depending on your particular situation, other flap options to create the new breast may include:

  • Latissimus dorsi flap: Uses tissue from the upper back
  • Superficial inferior epigastric artery (SIEA) flap: Uses tissue from the lower abdomen
  • Superior or inferior gluteal artery perforator (SGAP/IGAP) flap: Uses tissue from the buttocks
  • Transverse rectus abdominus myocutaneous (TRAM) flap: Uses tissues from the lower abdomen
  • Transverse upper gracilis (TUG) flap: Uses tissue from the inner thigh and underlying gracilis muscle

The TUG flap and SGAP/IGAP flaps are generally used with patients who lack enough abdominal tissue for the DIEP or SIEA flap.

Perforator Flaps

Using flaps of a woman’s natural tissue for breast reconstruction can be done without transferring muscle tissue when the flap includes a perforating blood vessel. Perforator flaps promise optimal cosmetic results without the loss of muscle strength. While procedures vary based on where the perforator flap originates, the general approach usually is the same. A flap of skin, fat, and blood vessels is carefully detached from one part of your body, then reattached and shaped into a new breast at the mastectomy site. At MUSC Health, two surgeons accomplished in complex microsurgery will work together to reconnect the blood vessels, shortening the time of the operation.

One of the most successful perforator flap procedures uses a DIEP flap, which is taken from the abdominal region, where many women have fat and skin to spare. In some cases, though, using the DIEP flap is not always possible, or there may be better options. The decision about which type of flap to use is based on many factors including the amount of tissue available at the donor site, desired breast size, expected scarring, and the patient’s surgical history. We will help you to determine the solution that works best for your situation.

You may not be a flap candidate if:

  • You do not have enough body fat to make the size breast that you desire.
  • You wish to avoid a donor site scar.
  • You have had previous surgeries that have injured perforating vessels.
  • You have a medical condition that limits your ability to withstand general anesthesia for an extended period of time.
  • You require systemic anticoagulation (blood thinners).

Perforator Flap Procedures

DIEP Flap (Abdomen)

While it is a complex process that requires advanced microsurgery, use of the DIEP flap has emerged as one of the most effective and desirable options for breast reconstruction.

The name of the flap comes from the main blood vessel that runs through it – the deep inferior epigastric perforator – which is located in the lower abdomen. During the procedure, an incision is made from hip to hip near the bikini line to access the blood vessels that keep the skin and fat alive. The flap is then disconnected from the abdomen and positioned on the chest.

In contrast to the TRAM procedure, which also draws tissue from a woman’s abdomen, no muscle is relocated with the DIEP procedure. By sparing the abdominal muscles, patients experience less pain after surgery, enjoy a faster recovery, maintain their abdominal strength long-term, and have fewer abdominal complications, such as hernia. No muscle or motor nerves are damaged when the DIEP flap is removed.

As with the TRAM procedure, women who undergo DIEP reconstruction are able to enjoy a flatter abdomen with results that mimic a “tummy tuck.”

Stages of DIEP Reconstruction 

Stage 1: Main Procedure

The purpose of this first procedure is to remove the tissue flap from the abdomen, position it on the chest and keep it “alive.” During this stage, the plastic surgeon will remove the perforator flap from the abdomen, attach the tissue at the mastectomy site, striving to keep the tissue “alive.”

If reconstruction is going to be done at the time of mastectomy, the breast surgeon will leave a pocket where the plastic surgery team can position the transferred tissue. If time has lapsed since your mastectomy, a plastic surgeon will make an incision through your previous scars to create a space for the flap.

Once the flap has been harvested, the plastic surgeons go under the microscope and connect the vessels in the flap to the vessels in the chest wall and under the arm. While the transfer is complex, our plastic surgeons have performed this type of microsurgery hundreds of times, and they operate in pairs so you will spend less time under anesthesia. Reconstruction of one breast (unilateral) generally take three to four hours at MUSC, while reconstructing two breasts (bilateral) takes six to seven hours.

Afterward, you will remain in the hospital three to four days, first in ICU and then a step-down setting. This is not because you are sick – you will be up and walking the day after surgery – but to ensure that you have a nurse dedicated to monitoring the success of the transferred flap. Our success rate with DIEP and other free flaps is 97 to 98 percent.

Your surgeon often can fix minor problems that threaten a flap’s success while you are recovering in the hospital. Once you are discharged, you can expect your flap to live with you for the rest of your life, though the reconstruction is not complete.

Stage 2: Tweaking Stage

This stage is more cosmetic in nature and can be done as soon as three months after your first surgery. The outpatient procedure usually takes an hour and allows the surgeon to address issues with breast and abdominal issues.

If you underwent a unilateral reconstruction, your other breast can be lifted, reduced, augmented or enhanced with fat grafting to create symmetry between the two breasts. If both breasts were reconstructed, your surgeon might do some further shifting or shaping so the breasts match as much as possible. In addition, the surgeon can address scarring or “dog ears” – pointy ends of skin on the side of each hip where the flaps were removed.

Depending on the amount of tweaking that is necessary, nipple reconstruction may be able to be completed in this stage.

Stage 3: Nipple Reconstruction/Tattoo

If it is not done during Stage 2, nipple reconstruction can be completed at this time using local anesthetic in a clinic setting. As early as six weeks after nipple reconstruction, you will return to the clinic for the finishing touch – areola tattooing by our specially trained 3-D artist. The procedures can be scheduled at your convenience and do not have to be done immediately.

CT Angiogram

Before your DIEP breast reconstruction, a CT-angiogram of your abdomen and pelvis will be scheduled. This test produces images of the blood vessels in the abdomen and will help your plastic surgeon map out the defining blood vessels (perforators) and the rest of the abdominal vasculature prior to your surgery.

Before this scan, a contrast material is injected into a peripheral vein. You will then lie on an exam table that slides into the CT machine, a large machine with a hole in the center, and the X-ray tube will rotate around you. Total scan time is generally 20 minutes. You do not have to fast or do anything special to prepare for the CT-angiogram.

Unilateral & Bilateral DIEP Reconstruction

For the sake of symmetry, the DIEP flap is taken from across the abdomen, whether or not the tissue will be used to reconstruct one or both of your breasts. If you are having a bilateral reconstruction, the abdominal tissue will be divided between the two breasts. If you have a unilateral reconstruction, any leftover tissue will be discarded after the procedure.

Once you have had DIEP surgery, you cannot have it again. If you have one breast reconstructed with a DIEP flap and later need or desire reconstruction of the other breast, you will have to use tissue from a different area of your body, or use an implant.

SIEA Flap (Alternative to DIEP)

In some cases, the superficial vessels in a woman’s abdomen provide more blood flow to that area than the blood vessel harvested with the DIEP flap.

When that happens, the surgeon will use the superficial inferior epigastric artery (SIEA) as the main source of blood for the tissue that is being transferred from the abdomen for breast reconstruction.

Removing an SIEA flap is less invasive but is used less often because the corresponding artery is too small in the majority of patients. Your plastic surgeons will decide to use an SIEA or DIEP flap during the procedure once they’ve sized up your abdominal blood vessels.

The procedure for transferring the SIEA flap is otherwise very similar to the DIEP procedure as plastic surgeons use microsurgery to attach the blood vessels in the tissue flap to those at the mastectomy site. Either way, the abdominal muscles are left strong and intact.

Stacked DIEP

For a patient undergoing unilateral mastectomy and who has a combination of larger breasts and a smaller abdomen, all of the lower abdominal tissue may be needed for reconstruction. In this case, the surgery team creates two separate flaps and connects them through microsurgery to create one breast.

DIEP with Vascular Lymph Node Transfer

When lymph nodes under the arm are removed during mastectomy, it may cause the arm to swell (lymphedema). Vascular lymph nodes can be transferred from either the unaffected arm or the groin area to reduce the undesirable side effects. Vascular lymph node transfer can be done simultaneously with DIEP breast reconstruction or as a stand-alone procedure. If done in conjunction with a DIEP, the lymph node and DIEP flaps are harvested surrounding the superficial circumflex vessels in the groin.

Deep Inferior Epigastric Perforator Flap

. The DIEP (deep inferior epigastric perforators) flap uses fat, skin and blood vessels from your lower abdomen to rebuild your breast. Surgeons can also transfer a sensory nerve from the lower abdomen with the flap to restore sensation in the breast. When the flap is connected to the chest to reconstruct the new breast, nerves may be reconnected for restoration of some of the sensation lost with mastectomy. DIEP flap, compared to the TRAM flap procedure, may allow for a shorter recovery time since no muscles are used. The procedure may also reduce the risk of losing muscle strength.

Deep Inferior Epigastric Artery Origin

 The deep inferior epigastric artery (DIEA) arises from the terminal aspect of the external iliac artery deep to the inguinal ligament. The DIEA ascends from the lateral aspect of the rectus abdominis muscle toward the umbilicus. It ascends between the transversalis fascia and the peritoneum, where it penetrates the posterior aspect of the rectus abdominis muscle.

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