Are You A DIEP Flap Candidate?
The DIEP flap procedure has rapidly become the “gold standard” in breast reconstruction. While not every woman is a DIEP flap candidate, many are turned away when in fact they needn’t be.
Typical misconceptions 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.
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 most 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. That’s not the case. Healthy tissue (like a diep flap) is by far the best reconstructive option after radiation.
Most of the time this misconception 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 very rare for us to find these blood vessels are damaged to the point they cannot be used. In instances where the internal mammary blood vessels cannot be used for whatever reason, other blood vessels can be used instead (eg internal mammary perforators or thoracodorsal vessels).
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 typically outweigh the benefits – At PRMA we set an upper BMI limit of 40 as we have found that performing the procedure on women with a BMI greater than this significantly increases the rates of complications (especially wound healing problems).
Hope this info helps!
I would like to thank my plastic surgeon, Dr. Chrysopoulo, for sharing this valuable guest blog. We feel it is imperative for women to be informed and educated about the options there are for breast reconstruction. There is a lot of information that can be researched. The objective is to present accurate, evidence-based information so that women can be properly prepared to be part of the shared decision making process with their plastic surgeons. There are misconceptions and we work to try to dispel those misconceptions.
I would additionally like to reference item numbers 2 and 3 above as they relate to my personal experience and my own DIEP Flap surgery.
2. An umbilical hernia I had laparoscopic gallbladder surgery and an umbilical hernia repair approximately 8 years previous to my DIEP Flap surgery. I was asked at my initial consultation with Dr. C to find the records to determine if mesh had been used to repair the hernia. I was appreciative of the fact that Dr. C’s philosophy is not to order any unnecessary tests. Upon finding the records it was determined that no mesh was used. This emphasizes the importance of keeping track of your medical records. Had I not found those previous records confirming that mesh was not used, more tests would have been ordered to make that determination.
3. Previous Chest Radiation This was a very beneficial affect of my DIEP Flap surgery that I want to share. I had radiation to my left breast area 12 years previous to my DIEP flap surgery. Although my daily activities were not encumbered, the range of motion in my left arm was notably different than my right arm previous to my reconstruction. I had that “tight rubber-band” feeling in my arm pit area that many women describe after radiation. I found it difficult to sleep on my left side due to discomfort. During my DIEP Flap surgery, Dr. C removed the scar tissue and radiated skin from my left breast and I now sleep on my left side quite comfortably and no longer have the tightness that I had previous to reconstruction. The plastic surgeons at PRMA have repaired many breasts using the DIEP Flap method that have been damaged by radiation.
With Gratitude to Dr. Minas Chrysopoulo in helping to inform and educate about DIEP Flap Breast Reconstruction.
