Abdominal Examination before DIEP Flap Surgery
Your plastic surgeon should perform a thorough abdominal examination before your DIEP flap surgery to determine the best possible outcome for your breast reconstruction. It is important to know that the abdominal tissue, both skin and underlying structure, is a reliable donor site to rebuild the breasts after a mastectomy. It is a fair question to ask the office of your plastic surgeon how much time will be spent at your initial consult, and what, if any medical history they will need to have prior to your visit.
Your plastic surgeon will review your overall health records. However, for this post I will concentrate on examination of your abdominal area and dedicate another post to your breast area examination. To give you some idea of what will take place and some terms used I took a careful look at my report and will describe to you from a patient’s research perspective what these terms mean.
Scars: Smooth, bumpy with a few lines in-between!
There is a term called abdominal striae that in non-medical speak simply means the topical impression of your skin. Are there stretch marks from past pregnancies or weight loss or gain? This is important when abdominal tissue will be moved from the tummy to create breast mounds. It becomes very important as in my case where I had both irradiated skin and delayed DIEP flap. My plastic surgeon was very clear that he would have to make larger flaps than he normally would if that were not the case. The condition and appearance of the abdominal skin is therefore an important part of the exam.
Previous scars will also be examined and what caused those scars. Perhaps it was from a cesarean section or in my case, lap chole scars. This is a medical abbreviation for laparoscopic cholecystectomy, also known as, laparoscopic gallbladder removal.
Layer Cake:
You will be checked for presence of fascial bulging. The various layers and underlying structure and implications of any bulging are important to the success of your surgery. All those layers and the condition they are in play an important role as they cut through them to reach the perforators. Without muddling the mind too much on the many layers and membranes that make up the abdominal wall, just think of your tummy as basically being made up of these layers and in this order from the top of your skin and down under!
- Skin
- Superficial facia: both fatty and membranous layers
- Muscle
Are you starting to understand the complexity of plastic surgery and in particular microsurgery and the ability and training your surgeon needs? Think of the perfect collision of art, science and skill! The length of DIEP flap surgery is often times a worry to patients but remember Michael Angelo did not build the Sistine Chapel in one day. Time is necessary in this type of surgery. Remember, each case is unique so full disclosure of any abdominal issues is a must and something for you to ponder and have available to discuss at your consult.
Oh Baby!
The elasticity of your abdominal skin, abdominal elastosis, will be determined. Mine was determined to be “mild”. This degeneration of elastic tissue can be the result of age, weight loss and gain or other reasons. If, in fact, mine was from age, I guess I’ll take the “mild” diagnosis. Oh yes, I can’t forget those two big boys I had, 8 lb. 13 oz. and 9 lbs. 10 oz.!
You will also be checked for rectus abdominis diastasis. Think of these terms:
- Rectus abdominis – abdominal muscles
- Diastasis – separation
This is a condition that occurs during pregnancy when increased tension is put on the abdominal wall. If rectus abdominis diastasis, the separation between the two sides of muscles in your tummy, is present and significant based on measurement, you will have to discuss this with your plastic surgeon and the implications to your DIEP flap surgery.
Fat is our friend
There will be a determination of abdominal adiposity. And what, you might ask is that fancy term? It’s fat accumulation. Let’s just say, be prepared to have your tummy pinched! Fat matters in this surgery but I promise the pinch won’t hurt. Unless it is obvious that you have enough abdominal tissue, a pinch will be necessary to determine if you have enough tummy tissue to make that breast mound and the size the plastic surgeon can best predict that he can get you to post DIEP flap procedure.
Expected patient outcomes and the size of your breasts are part of the shared decision making process during this exam. I was and still am amazed at the number of people who have never heard of DIEP flap surgery. This is why I have continued to educate and inform others not only about DIEP flap and other breast reconstruction options but also to let women know about the process and what to expect. On a lighter note, expect friends and relatives to offer and willingly “donate” some fat for you for your new breasts. I got that a lot and loved the jovial exchange when it happened.
Pencil Doppler evaluation
Remember, this is called Deep Inferior Epigastric Perforator (DIEP) flap surgery. So, those perforators need to be checked for viability prior to surgery. The nurse at my plastic surgeon’s office brought in a pencil Doppler. She took the pencil Doppler and applied the jelly to my tummy area. She glided it over my belly to determine good venous and blood flow. I will always remember that moment for two reasons. First of all I was very happy to hear a healthy “whoosh, whoosh” pulsing sound from the small Doppler. That translated into good blood flow and good perforators for the DIEP flap surgery. Secondly, my plastic surgeon stood by to listen as the nurse used the Doppler. She was very pregnant at the time, as in, due in just a few weeks pregnant. When she placed the pencil Doppler over my belly and we heard the pulsing of my perforators she looked at me and smiled and said, “It’s a girl!” It did sound very much like the beautiful in utero heart beat of a baby. I’m happy to report that nurse had a beautiful baby girl and I have two new beautiful breasts. Yay for viable heart beat sounds, babies and perforators!
CT Angiogram
Your plastic surgeon may also feel the need to order a CT Angiogram before your surgery. It is not always the case but my own plastic surgeon, Dr. Minas Chrysopoulo, has written an excellent description here. Following is a brief quote from the article he wrote.
A CT angiogram (CTA) is a special type of CT scan that evaluates the blood flow in the abdomen to determine if the required blood vessels are intact and able to be used for DIEP flap reconstruction. It can also provide a “road map” for the surgeon and help locate the larger blood vessels (perforators). Rarely, the vessels needed for the DIEP flap may have been damaged by previous abdominal surgery. ~ Dr. Minas Chrysopoulo
I hope this helps you understand a bit more of the necessity and understanding of your abdominal examination. Again, I will address your breast examination before DIEP flap surgery in a later post with more information and more intricacies.