Part IV: Flap-based reconstruction – DIEP flap
The use of microsurgery and perforator flaps, such as the DIEP flap, is the newest and state of the art technique for plastic & reconstructive surgery today, including breast reconstruction. Very few plastic surgeons perform this technique due to its complexity, time, and skill involved, but such reconstruction arguably provides the best aesthetic outcome with less morbidity, since only perforating vessels are utilized and muscle is not sacrificed for the flap reconstruction, for those women who are candidates for this unique procedure. However, it is a very popular technique elsewhere in the world and by those few surgeons who perform it in the United States. It is a procedure that has been refined through my fellowship training, and one in which women throughout the United States consult for to perform this innovative type of breast reconstruction, such as the DIEP flap.
Like the conventional TRAM flap procedure, the perforator flap DIEP breast reconstruction offers the advantages such as those offered by the TRAM flap, however, without the sacrifice of the rectus abdominis muscle – only the excess skin and fat from your lower abdominal wall is harvested for the flap…the muscle is left intact on your abdominal wall. This gives the distinct advantage of a completely autologous breast reconstruction, without need for an implant. In addition, since it is a muscle sparing procedure where the rectus abdominis muscle is not sacrificed, your abdominal wall integrity is maintained, leaving a much lower chance of bulges or hernias after the procedure than the TRAM flap.
The flap and its blood vessels are then disconnected entirely from the body, and the entire flap is then relocated to its new location in the breast area as a free tissue transfer. Its corresponding blood vessels are then reattached to blood vessels in the nearby area, using microsurgical techniques. Afterwards, the entire flap may be turned, twisted, or inset in the best position possible to contour a new breast for you. The conventional pedicled TRAM flap is limited in its insetting since it remains attached to its muscle insertion and blood supply superiorly.
Much like a tummy tuck, your abdominal incision will be sutured closed, first by repairing the abdominal wall, then by suturing your incision, leaving a single incision at the lower abdomen, hidden within your bikini line. To finish the closure, your umbilicus (belly button) will be brought out through a small incision, and sutured at its normal anatomic location.
· Hospitalization: 5-7 days
· Advantages: Same as for the TRAM flap, but decreased hernia/bulge risk due to the fact that the muscle is spared and abdominal wall integrity maintained
· Disadvantages: Same as for the TRAM flap; complex procedure; abdominal wall integrity maintained (minimal hernia/bulge risk – much less than conventional TRAM flap)
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