DIEP or SIEA Flap Candidate?
Many women have asked if they are good candidates to undergo such a complex procedure as the DIEP flap for breast reconstruction. Many have been denied by other surgeons for various reasons. I have been asked if I would share some thoughts on who would be the ideal candidate for this type of microsurgical breast reconstruction.
In a nutshell, every woman is a candidate for breast reconstruction. Specifically, there are several types of microsurgical, muscle-sparing, perforator flaps that may be used to obtain an aesthetically pleasing breast reconstruction. Not only is there the DIEP flap and the SIEA flap (which are flaps obtained from tissue from the lower abdomen), but there are also the SGAP/IGAP flap (gluteal tissue), TAP flap (back tissue), ALT flap (lateral thigh tissue), TUG flap (groin tissue), and other donor sites that are continually being found. Certainly these microsurgical, muscle-sparing, perforator flaps are highly complex procedures that usually requires specialized training due to their complexity, and, since they have recently gained in popularity and prowess for their minimal donor site morbidity, decreased complication rate, muscle-sparing nature, robust blood supply, and aesthetic results, very few surgeons have the training and skill to perform such procedures. Many surgeons may not offer, let alone discuss, such types of reconstructive options, which are certainly at the forefront of breast reconstruction today. Certainly there are some risks and potential complications that may occur with such a complex procedure, which should be discussed with your plastic surgeon, but with the advent of these procedures, they should be included in any discussion about breast reconstruction.
You do not have to be overweight to be a candidate for the DIEP flap. This procedure has been successfully performed in women of all Body Mass Indices (BMI’s). Gaining weight will not increase the success rate or the result obtained. In fact, sometimes it makes it more difficult. What is known is that the overall risk for surgical complications increases with BMI >35 and significantly increases with BMI >40.
Medical comorbidities, such as heart and lung problems are also a major concern. Your primary physician should medically clear you for the surgical procedure prior to undergoing such a lengthy procedure to maximize your health prior to, and after your surgical procedure. Diabetes also increases the risk of small-vessel disease, wound healing complications, and infection. Great success has been obtained in diabetics after achieving stable glucose control with minimal increased complication rates. Smoking also does the same and cessation should be done at least 6 weeks prior to any surgical procedure. Your overall health will be considered by your plastic surgeon.
Previous abdominal surgery has not significantly increased failure rate, with few exceptions. Women who have previously had an abdominoplasty (tummy-tuck) are not candidates for this procedure. The perforating vessel which would have been used to sustain the flap, have unfortunately been cut already, making this flap unusable. The same holds true for those who have previously had a DIEP/SIEA or TRAM flap procedure in the past. I co-authored a paper while at the Mayo Clinic which looked at success rates of the DIEP flap after laparoscopic gynecologic procedures. There were no increased failure or complication rates to those who did not have ay such procedure performed in the past. Hernias, unless massively large with multiple complex abdominal repairs and/or abdominal wall reconstructions, also have not been shown to preclude one from a DIEP flap. Previous appendectomy, hysterectomy, c-section also are still viable candidates. Another paper through the Mayo Clinic, we looked at obtaining CT angiograms prior to the DIEP flap for evaluation of the vasculature as well as surgical planning. This will certainly help if there is any question regarding viability of the flap for use. We utilize this imaging routinely.
Previous chest irradiation also has not hampered the success rate of any microsurgical breast reconstruction. In fact, it has ameliorated it. Bringing in such a robust blood supply from this microsurgical flap helps the irradiated tissue of the chest. Also, we have not seen any increased damage to the vessels that we utilize in the chest to perform the microsurgery. Several papers have shown this to be true. As discussed before, a flap procedure is the wisest thing to do if previous radiation therapy was done.
Overall, the DIEP/SIEA flap is a great option for breast reconstruction. All women are candidates for breast reconstruction and a thorough conversation with your plastic surgeon should be done to determine WHICH procedure would be the best for YOU…which should include a discussion about microsurgical flap procedures. This should answer many of the questions about candidacy for the DIEP flap or SIEA flap. Even if you may not be a candidate for abdominal tissue procedures, there are other flaps which may be considered as discussed above.
Women have sought the DIEP flap from all over the Phoenix, Scottsdale, Tucson area and Southwest have had great results with our DIEP flap. We have had women travel from throughout the United States to have the DIEP flap, SIEA flap, SGAP flap, and other microsurgical reconstructive procedures.
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