Dr. Oscar Ochoa discusses the difference between APEX and DIEP flap reconstruction. I am asked this question on the DiepCJourney Facebook page often enough and knew it was time to reach out to an expert. Dr. Ochoa is with PRMA in San Antonio, Texas. They celebrate thirty years of service to the breast cancer community this year. Congratulations to the growing team of surgeons providing breast reconstruction worldwide for patients.
Learning About the Philosophy of Plastic Surgery in Breast Reconstruction
Dr. Ochoa tells us in the video,
Breast reconstruction is a topic that no one really learns about until they are actually dealing with it.
~ Dr. Oscar Ochoa
Before we begin the slide presentation discussing the nuances of the APEX vs. the DIEP flap, Dr. Ochoa begins our discussion talking about the overall philosophy of plastic surgery. He tells us this philosophy is based on replacing like with like. Their goal is to perform breast reconstruction in such a way that results in a natural breast that is soft, warm, and very much like the natural breast using abdominal tissue.
Back when abdominal tissue began to be utilized for breast reconstruction, there wasn’t a lot of knowledge about putting blood vessels together. There was use of the skin and fat to use but often times the muscle would have to be removed as well because the muscle was carrying the blood vessels providing blood flow to this tissue. The muscle itself was not really providing a lot of volume. But the muscle was taken with the skin and fat just as a vehicle to transfer the blood vessels with it. That was really the only function of the muscle.
As the plastic surgery community was doing more of these, they were observing that patients were complaining. They were having issues with abdominal wall weakness because a part of their rectus muscle was taken with their breast reconstruction. This surgical procedure evolved over time using less and less muscle and the DIEP flap was developed.
The DIEP Flap Breast Reconstruction
DIEP flap breast reconstruction leaves all the muscle behind taking only the blood vessels, the fat, and the skin to do the breast reconstruction. This ideally allows women to maintain all their abdominal core strength. This is done by selecting very small blood vessels and leaving everything else behind. Now they are often able to take sensory nerves as well to regain sensation to the breast after the breast reconstruction.
The blood vessels that provide blood flow to the lower abdominal area (as shown in the slide presentation) originate in the pelvis. Dr. Ochoa describes the anatomy of these blood vessels to patients in this way. He tells them to think of it as a tree with the tree trunk being located in the pelvis. As the blood vessels are traveling upward, they give off branches. Those branches penetrate through the rectus muscle (the vertical six-pack muscle) on our abdomen. These blood vessels supply the skin and fatty tissue of the lower part of the abdomen. Think of the “canopy of the tree” as the skin and fat.
During the DIEP flap the surgeon finds the largest branches of that tree. Most of the time those branches are in sort of a single file along the lengthwise fibers of the rectus muscle. They choose one or two of the strongest blood vessels between these muscle fibers, gently separating the muscle fibers that are in line with the blood vessels. I like his analogy of “pruning the tree.”
The APEX Flap Breast Reconstruction and How it is Different from DIEP flap
Dr. Ochoa describes the evolution of the DIEP flap and refers to the APEX flap as “sort of a cousin” to the DIEP flap. In certain situations, the dominant branches do not align with the muscle fibers. There are times when the main blood vessels are actually along two separate plains of muscle fibers. To take those two very necessary branches, the surgeon would have to cut the muscle across to be able to take those two branches. That is not what Dr. Ochoa says should be done. Why? Because now you have the potential to negatively impact the strength of the muscle.
This is where the APEX flap comes in. When the blood vessels are in two separate plains they must independently dissect those branches around the muscle and disconnect them. The surgeon will disconnect them temporarily, leaving the muscle intact, extracting the skin, and fat and blood vessels. Once it is moved away from the muscle, these main blood vessels (branches) can be reattached again. This saves the strips of muscle fibers that are in-between these two branches and keep the rectus muscle completely intact. This is illustrated in the video below. I describe the process to Dr. Ochoa as a “replumbing” technique. He nods his head in agreement.
The Difference Between APEX and DIEP Flap Reconstruction
Patients sometimes ask Dr. Ochoa if he will know ahead of time if they will need an APEX flap or will they have a DIEP flap. He tells us most of the time surgeons don’t know for sure and it is not until they are in the operating room and they find the exact location of those blood vessels. It is then they determine if the reconstruction will best be done with an APEX flap or something that can be done with a standard DIEP flap.
We hope the discussion and presentation help patients understand the difference between APEX and DIEP flap reconstruction. You can watch the video below and please let us know if you have any questions.
I would like to express a personal thanks to Dr. Ochoa. He is the co-surgeon who was on the team with Dr. Minas Chrysopoulo. They are the surgeons who performed my DIEP flap breast reconstruction in December of 2014. It is hard to believe it has been ten years since I was in San Antonio traveling for my surgery.