Episode 19: Efficient DIEP Flaps

DIEP flaps are a type of breast reconstruction using a patient’s own tissue to reconstruct breasts after mastectomy for those affected by breast cancer. DIEP stands for deep inferior epigastric perforators. Epigastric refers to the abdominal area. The underlying tissue and perforators (blood vessels) are disconnected by the microsurgeon from the abdominal area and transplanted to the breast area to create soft, warm, tissue much like the breasts removed during mastectomy. We hope Episode 19: Efficient DIEP Flaps, has piqued your curiosity.

Efficient DIEP Flaps Study

To do an efficient DIEP flap requires years of training, skill, planning, and a team. My guest, Dr. Nicholas Haddock is one of the Breast Reconstruction Team at UT – Southwestern Department of Plastic Surgery in Dallas, TX. He works with Dr. Sumeet Teotia performing state of the art autologous breast reconstruction in the Dallas/Fort Worth area in Texas.

In our discussion we reference the PRS Global Open paper he authored with Dr. Teotia titled, “Efficient DIEP Flap: Bilateral DIEP Flap in Less Than Four Hours”. PRS Global open is a free resource available to everyone. I heard Dr. Haddock in an interview of the Resident Review podcast discussing this paper. It was the impetus for my interview with him.

Our goal for the conversation in this episode of the DiepCJourney Podcast is to inform and educate patients about the value of a team approach and to consider questions to ask at their own surgical consult for breast reconstruction.

Collaboration with a Team to Perform Efficient DIEP Flaps

Many patients fear the unknowns of this surgery. One of the biggest concerns is the time of the actual surgery. Dr. Haddock points out that patients are presented with DIEP flaps in a lot of different ways. He goes on to say, unfortunately, depending on the bias of the surgeon you can make it sound like a horrible operation or you can make it sound like a great option.

Working together as a team with Dr. Teotia, their goal over the years has been trying to optimize DIEP flap operations. Efficiency has become one of their more recent focuses. With the national average for DIEPs being nine plus hours. This amount of time is what is concerning to patients and why they may choose not to have this type of breast reconstruction. He points out if the operation can be done routinely in four hours, most patients can swallow that a little better.

Dr. Haddock finds that in his practice the more efficient they get, the more focused they get, and they also see lower complications rates. This is critical in medicine to assure patients that efficiency translates into safety. The concept of efficiency is not just about efficiency. It is about doing things better.

What Makes the Team Efficient?

Dr. Haddock has a team that is all inclusive. He says they cannot do this without every member being on board. This team starts at the front office with his administrators and nurses in clinic. The team continues in the O.R. with the anesthesia colleagues, scrub techs, and nurses.

Dr. Haddock speaks about the importance of the system they have developed. He does a lot of this type of surgery so he sees the same team members who are with him every day. Because of this we both agree it is a “well-oiled machine.” It is reassuring to hear his comment,

There is no question: Do we have the instruments ready; do we have the microscope ready; it just flows making it a very pleasant place to work.

Dr. Nicholas T. Haddock

He points out this helps his patients because it continues into post-op care. Dr. Haddock explains the misnomer that a DIEP flap patients need to recover in the ICU. Some patients have a fear of DIEP flap thinking they have to recovery in ICU. The floor his patients recover on is a dedicated floor that looks like a regular hospital room. Patients do not need ICU from a medical standpoint but because the flap needs to be monitored it is done on a floor with a patient to nurse ratio that can handle this.

Alternate Flaps

Dr. Haddock also mentions alternate flaps they perform at his practice. He was fortunate in medical school to train with Dr. Bob Allen, often considered the “DIEP Guru” in plastic surgery. Dr. Haddock did his first PAP, profunda artery perforator, flap tissue from the back of the buttock with Dr. Allen. He considered it pure luck to have trained under Dr. Allen and did the first twenty-seven PAP flaps with him. Because of this experience, he was able to bring it back to the Dallas area. Now known for his work in PAP flaps, he says he gets a fair amount of referrals for him to perform this surgery for patients. They have performed over four hundred to date.

The LAP, lumbar artery perforator flap, uses the tissue from the love handle, or flank area of the patient’s back. Here are some things Dr. Haddock tells us about the LAP flap.

  • Most patients, even thinner patients, have enough fat in this area to form a breast.
  • The lumbar tissue is a little thicker than the DIEP flap abdominal tissue thereby giving it a nice shape for the breast.
  • Patients must be turned multiple times during the LAP flap. Many surgeons will have patient return to complete an opposite side but their efficiency in the O.R. has allowed his team to complete these types of surgery in one day.
  • Complications he sees with LAP flap can include seromas in the back area. For this reason, he tends to keep the drains in for a bit longer than a DIEP flap.

CTA as Part of Efficient DIEP Flaps

A CTA (Computed tomography angiography) maps the blood vessels of the patient’s body. Dr. Haddock orders this on all his patients. He feels knowing where these optimal blood vessels are prior to surgery cuts down on the time need to look for them in the O.R. He routinely maps the tummy, buttocks area, and lumbar area to find the optimal site to harvest a flap from for his patients.

When he has a consult with his patients, he discusses the results of the CTA having a candid conversation with them about what they prefer and will work best in their situation. I remind Dr. Haddock this is part of the shared decision-making process I am a big proponent of. Making the patient feel they are a team member in the decision is important to Dr. Haddock. I follow by adding he is honoring the patient by trusting they are capable and enthusiastic to receive the information to make an informed decision.

Final Words on Efficient DIEP Flap

Dr. Haddock mentions the value of using ERAS protocol at his hospital facility. The additional use of liposomal bupivacaine and exparel have improved recovery for patients. Administering these TAP blocks are allowing patients to get back on their feet quicker allowing their bodily functions to get back to normal faster.

He fully intends to continue to improve the work he is doing. Dr. Haddock wants the process of efficient DIEP flaps to carry over into the work of the residents he teaches, inspiring them to be their best, and do their best.

You can listen to the entirety of Episode 19: Efficient DIEP Flaps here:

Disclaimer

References made to my surgical group, surgeon and healthcare team are made because they are aligned with my values and met my criterion after I did research of their practices and success rates. Any other healthcare provider that displays the same skill, compassion education and outreach to patients will be given consideration and recognition on this website.  The information contained on this website is not a substitute for or should be construed as medical advice. Please consult a licensed physician for medical advice.