Looking at the analytics on the DiepCFoundation YouTube channel I realized this video, DIEP Flap reducing abdominal wall complications with Dr. Minas Chrysopoulo is worthy of a blog summary. For our viewers, some value watching the video while others find it helpful to read the information. Having in a blog will allow you to print it if you feel it will help you at your surgical consult. Speaking to your surgeon about reducing abdominal complications in DIEP flap breast reconstruction is an important part of the conversation.
Hernia and Bulging in DIEP flap Breast Reconstruction
Dr. C begins our conversation with “Well, you know how I feel about the belly”. I agree and point out the other video we did on the topic, “The Aesthetics of the Belly in DIEP flap Breast Reconstruction”. Dr. C and I like to share these across multiple channels. This video can also be found on the Breast Advocate® YouTube channel. As a reminder, Dr. Chrysopoulo is the Founder of the Breast Advocate App, a free breast cancer surgery app that provides ALL your surgical options along with evidence-based recommendations, personalized for you.
He shares with us that hernia and bulging are fairly uncommon in DIEP flap surgery. There is about a three percent risk of a bulge. Dr. C tells us a bulge is when basically everything is intact, but the tissues get a little bit loose or lax. This is also referred to as a “pooch”. A bulge can be caused by multiple pregnancies or previous abdominal surgeries. He goes on to share that a hernia is approximately a one percent risk. A hernia is when the strength layer under the skin on top of the muscles gives way. Everything under that bulges out becoming a hernia. A hernia is a hole in the fascia. The fascia is the strength layer.
Dr. C tells us the three key factors that increase the risk of bulging and hernia are:
- Lots of cuts in the fascia increases the risk.
- Removing muscle, increases the risk.
- Cutting a bunch of nerves that power that muscle with the purpose of maintaining its tone.
Reducing Wound Healing Abdominal Wall Complications
Dr. C says wound healing is probably the number one abdominal wall complication in DIEP flap. Wound healing issues occur more frequently in ladies with the following conditions:
- Higher BMI
- Diabetic patients especially if they are not very well controlled in terms of their blood sugars.
- Smokers, “smoking is a big no no” when considering breast reconstruction plastic surgery.
I chip in from a patient perspective pointing out important questions patients should ask their plastic surgeon at their consult. These are questions I feel are valuable:
- How often do you deal with wound healing in the belly area?
- What is your success rate in repairing any complications if they occur?
- What methods do they use to reduce these complications?
Dr. C states that any prior abdominal surgeries can also increase your risk of wound healing.
Motor Nerves in the Abdominal Area
He provides an easy-to-understand explanation of the importance of the motor nerves. Dr. C explains by example with the case of a person who is paralyzed. I share that I know a paraplegic, someone in a wheelchair who is paralyzed from the waist down. He says the muscles in their legs have wasted away with absence of muscle bulk or tone. The muscle is still there. However, because they are paralyzed the motor nerves that were feeding it, powering it, and getting it to move (function, twitch, and contract), that ability has been removed because of the spinal injury. The muscle then wastes aways, or atrophies.
The same thing can happen to your rectus muscles, your sit up muscles. If the DIEP flap surgeon goes in, and because it is a DIEP flap, they are preserving all the muscle, but they DON’T pay attention to the nerves coming into the muscle to power it, that is not good. You can say you saved all the muscle if you are doing a DIEP flap. But if you don’t save the motor nerves powering the muscle you are not doing the patient any favors.
Preventing Damaging to the Motor Nerve to Reduce Abdominal Wall Complications in Diep Flap Breast Reconstruction
- Look out for the nerves and preserve them.
- If a nerve must be cut to access the important blood vessels, the surgeon should then repair it.
Dr. C very honestly shares with us that the reality is, not all surgeons do this and not all feel so strongly about it. He points out he is expressing his opinion from the surgeons he practices with at PRMA. The procedure they use goes into the muscle, not cutting it out to get to those important blood vessels in the flap that supplies the warmth of the new breast.
This surgery can present challenges for the plastic surgeon when more than one blood vessel is needed and not running in an ideal manner through the rectus muscle. They make use of surgical tools like the SPY technology to assess the blood vessels intraoperatively. The visual explanation using his hands in the video will give you a good understanding of why they must carefully dissect the blood vessels out of the muscle and sometimes utilize a blood vessel in another area of the abdominal wall. It is a complicated, tedious process. This is microsurgery!
The APEX Flap in Optimizing the Abdominal Wall in Breast Reconstruction
No two muscles are created equal. He segues into an explanation of the APEX flap, a type of DIEP flap. I give Dr. C a moment to draw a diagram in the video. He shows how the rectus muscle appears in a vertical fashion in the abdominal area. The blood vessels, the perforators, are pointed out in the illustration. He shows the larger blood vessel feeding the smaller ones running through the muscle fibers that will be used to connect to the vessel in the chest. Dr. C shows how they go under the muscle rather than cutting the muscle so they have access to the perforators. Then they are reconnected after they are retrieved.
He describes the APEX as “replumbing” rather than cutting the muscle. It is pulled away from the muscle. Dr. C completes this step while he is working on the belly and before the flap is transferred to the breast area to be connected to the blood vessels there. The terminology, the vocabulary, when there is something new in terms of description, can become confusing to patients. Not everyone needs an APEX. You will not know if you are going to need an APEX until the surgeon exams the blood vessels in the abdominal area as the surgery begins.
Important Questions to Ask Regarding Minimizing Abdominal Complications
Dr. C and I talk about the information patients sometimes lack about minimizing abdominal complications. Here are important ones he shares to ask:
- If you need two perforators, do you cut the muscle or do you do an APEX flap?
- If you cut the nerve or nerves, do you repair it?
- When would you repair it?
- Why wouldn’t you repair it?
Be informed, understand terms, and know what you are asking about. Also ask what you can do to reduce risks as a patient prior to surgery and during recovery. It is a team event. The combination of having an informed discussion with your surgeon and doing what you can to minimize abdominal wall complications is that best team effort.
This is one of the most powerful comments made on the channel after a DIEP flap patient watched the video.
This was probably the most informative video I have watched so far for my upcoming DIEP surgery. I feel much more empowered now to discuss this surgery with my surgeons. Well done!
DIEP flap patient