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DIEP Flap Breast Reconstruction

Many different techniques are available for breast reconstruction. These include implant-based reconstruction, and autologous tissue-based reconstruction techniques (breast reconstruction using your own tissue). While an implant-based reconstruction offers patients a shorter surgery and recovery period, implants are temporary devices and will not last a patient for her lifetime. Also, most studies have shown that implants used for breast reconstruction in women who have had or will have radiation therapy have an extremely high complication rate – which can range between 60%-80% with a very high rate of reconstructive failure. Furthermore, many of these women will ultimately require an autologous tissue based reconstruction to salvage their reconstruction.

Thus, for women who have had or will have radiation therapy, and for young women with active lifestyles, an autologous tissue based reconstruction is the best alternative. Autologous tissue breast reconstruction techniques use a woman’s own tissue to make breast – these techniques include the pedicle TRAM flap, the free TRAM flap, the muscle-sparing TRAM flap, and the DIEP flap. The Deep Inferior Epigastric Perforator (DIEP) flap offers women undergoing breast reconstruction a natural-appearing breast with minimal trauma to the donor site.

The pedicle TRAM flap uses the lower abdominal tissue to make breast. However, this tissue gets its blood supply from the underlying rectus abdominis muscle (six-pack muscle). Because the muscle is taken with the lower abdominal skin and fat, with the pedicle TRAM flap, women typically notice abdominal weakness due to a loss of muscle. They may develop bulges of the abdomen or hernias, and will have difficulty sitting up. Most women who have had a bilateral TRAM reconstruction will complain that they are severely limited with their physical activity.

A DIEP flap allows the skin and fat from the lower abdomen to be used to make a new breast without sacrificing the underlying muscle. This means that most women are able to resume their normal physical activities – such as working out, sit-ups, and playing with their children – with a much lower risk of developing abdominal weakness, hernias, or abdominal bulges. Also, because the DIEP flap uses a woman’s own tissue, the reconstructed breast will feel like her own tissue and will look more natural.

DIEP flap breast reconstruction replaces the skin and soft tissue removed during mastectomy with soft, living tissue by taking skin and fat from the abdomen. An incision is made along lower abdomen above the pubic hairline. The perforating blood vessels from the rectus muscle to the overlying skin and fat are identified and dissected to their origins. The necessary skin, soft tissue, and feeding blood vessels are removed; the blood vessels are then reconnected to blood vessels in the chest under a microscope.

Unlike conventional reconstructions, the use of the DIEP flap allows for collection of the lower abdominal tissue without sacrifice of the underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. In addition to reconstructing the breast, the contour of the abdomen is often improved similar to a tummy tuck.

Commonly asked questions regarding the DIEP flap:

1) What is the DIEP Flap?

A DIEP flap is a type of flap used for breast reconstruction. DIEP stands for deep inferior epigastric artery perforator flap and is essentially the name of the blood vessels that provides a vascular supply for this flap. It takes the lower abdominal skin and fat between your belly button and pubic bone without taking the muscle and uses this tissue to make a breast.

2) How is this flap different from a TRAM flap?

A TRAM flap also uses the lower abdominal skin and fat but usually takes the underlying rectus abdominis muscle with it to provide the vascular supply.

3) What are the advantages of a DIEP flap?

A DIEP flap allows the skin and fat from the lower abdomen to be used to make a new breast without sacrificing the underlying muscle. This means that most women are able to resume their normal physical activities – such as working out, sit-ups, playing with their children – with a lower risk of developing abdominal weakness, hernias, or bulges. Also, because the DIEP flap uses your own tissue, the reconstructed breast will feel like your own tissue and will look more natural. Implants will feel like implants and will look like implants, particularly when you see yourself without clothes.

Additionally, most studies have shown that women who have a DIEP flap for breast reconstruction have less post-operative pain following surgery when compared with women who have had tissue expanders or TRAM flaps. Other large studies have also shown that these women have a higher long-term satisfaction rate with their reconstructed breasts than women who have had implant-based breast reconstruction.

4) Who performs the surgery?

Dr. Anu Bajaj performs the surgery with the assistance of her father, Dr. Paramjit Bajaj. Both are board-certified plastic surgeons. Dr. Anu has received additional microsurgical training at the University of Texas MD Anderson Cancer Center. Dr. Anu Bajaj has been practicing plastic surgery and routinely performing DIEP flap breast reconstruction in Oklahoma City since 2007. This means that she has performed over 500 such flaps with a flap failure rate of less than 1%. Prior to moving to Oklahoma City, she was on the faculty at the University of Cincinnati School of Medicine.

5) How many of these procedures do you do?

On average, we perform 50 free flaps a year. A free flap is a procedure that involves microsurgical expertise to reconnect the blood vessels. Prior to moving to Oklahoma City, Dr. Anu performed 2-3 free flaps per week while in Cincinnati, Ohio. Since moving to Oklahoma City, she has performed over 500 DIEP flaps.

6) Where is the surgery performed?

Dr. Anu Bajaj performs all of her DIEP flap procedures at Saint Anthony Hospital in Oklahoma City. Saint Anthony has a new state-of-the-art operating room and has purchased the specialized microsurgical equipment – including a new microscope, flap monitoring devices, and a trained operating room team – which she requested.

7) How long does the surgery take?

The surgery usually takes 3-4 hours for one breast and 6-8 hours for two breasts. This length is not significantly longer than what it takes for a pedicle TRAM flap. Because the DIEP flap is performed routinely at St. Anthony Hospital, the nursing and operating room staff are familiar with the procedure and are able to provide quality care to all patients.

8) Can I have my reconstruction performed at the same time as my mastectomy?

Yes. Women with early stage breast cancer who will not require radiation therapy or those women who are having prophylactic mastectomies are candidates for immediate breast reconstruction.

9) What will my recovery be like?

Most patients spend 3 days in the hospital after surgery.

Typically, women will take 6-8 weeks off of work as well. Drains are usually removed within 7-10 days following surgery; and most women feel comfortable driving at 10-14 days following surgery. Women who have flexible jobs have been able to return to light duty at work as early as 3-4 weeks following surgery.

10) Will I have pain after a DIEP flap?

Unfortunately, all surgery will involve some degree of discomfort. Dr. Bajaj employs many techniques including ERAS (enhanced recovery after surgery) pathways to assure that your recovery will go smoothly. These pathways involve a multi-pronged approach to surgery to minimize your discomfort and includes: patient education, aggressive management and prevention of post-operative nausea, and the use of multiple methods of pain control including local anesthetics, anti-inflammatories, neuro-modulators in addition to more traditional narcotics. Furthermore, recent studies have shown that women who undergo a DIEP flap have less post-operative pain and a faster return to work than many women who undergo breast reconstruction with a tissue expander.

11) Can I speak with your patients?

When you come for your initial consultation, you may obtain a list of patients who have had a DIEP flap performed for breast reconstruction by Dr. Anu Bajaj and Dr. Paramjit Bajaj. These patients have agreed to speak with you and discuss their experience with you.