The document discusses breast reconstruction options after mastectomy for breast cancer patients. It focuses on the DIEP flap procedure, which uses a woman's own abdominal tissue for reconstruction. In a DIEP flap, the deep inferior epigastric vessels are detached from the abdomen, leaving the rectus abdominus muscles intact. This spares muscle function and strength compared to other flap procedures. The vessels are reattached under the breast to restore blood flow. DIEP flaps provide a natural breast reconstruction with less risk of abdominal bulging or weakness than other options. Recovery typically involves 3-4 days in the hospital and limited activity for 6 weeks.

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INFORMED PATIENT / HOUSTON
ILLUSTRATIONCOURTESYOFMEMORIALPLASTICSURGERY.
Changing
With The Times
DIEP Flap: A More Effective
Breast Reconstruction
BY DR. KENDALL R. ROEHL
BOUT 1 IN 8 U.S.WOMEN, or roughly 12 percent, will
develop invasive breast cancer over the course of their
lifetime. In 2016, an estimated 246,660 new cases of invasive
breast cancer are expected to be diagnosed in women
in the U.S., along with 61,000 new cases of non-invasive
breast cancer. Because of its prevalence in women,
reconstructive surgery after breast cancer has consumed
a large portion of many plastic surgeon’ practices. The
American Society of Plastic Surgeons reported 102,215
breast reconstructions were performed in 2014. This was
a 30 percent increase over the 78,832 reconstructions
done in 2000, and breast reconstructive surgeries
continue to rise.
In breast restoration, women have three options for
reconstruction after mastectomy: implants, their own
tissue, or a combination of implants and their own
tissue. Implant-based breast reconstruction was the first option available
to women with breast cancer, and it remains the most common form to
date. However, as of 1982, women also have the option of using their own
tissue to reconstruct their breasts. There are multiple options available for
natural tissue breast reconstruction, but the most favorable is the lower
abdominal tissue.
The original
version of this
reconstruction was
called the transverse
rectus abdominus
myocutaneous flap,
or TRAM flap, and
it used the tissue from the belly button to the pubic hair and hip bone
to hip bone to reconstruct the breast. The abdomen, or donor site as it
is referred to, is then closed similar to a cosmetic tummy tuck after the
abdominal tissue is transferred and shaped. However, this flap sacrifices
rectus abdominus, one of the six-pack muscles, in order to provide a
blood supply for the transferred skin and fat. The tummy tissue and
one six-pack muscle remain
connected, and they are swung
into the chest as one unit then
shaped in the form of a breast.
As time and science has
evolved, the abdominal flap-based
techniques have improved to limit
the amount of damage that is
done to the abdominal donor site
in borrowing this tissue to create
a breast. The flaps are referred to
as muscles-sparing TRAM flaps
and more recently deep inferior
epigastric flaps, or DIEP flaps as
they are commonly
referred to. The
two main benefits
of the DIEP flap
are that the entire
six-pack muscle
remains intact
and functional
on the abdomen
limiting weakness
and bulging of the
abdomen, as in the
TRAM flap, and
blood supply to the flap is hardier,
creating a more reliable transfer of
skin and fat to the breast with less
partial tissue loss after transfer.
DIEP flaps are performed
by the most technically skilled
and most highly trained plastic
surgeons in the world. Most
of these surgeons have spent
additional years training in
transplanting tissues called
reconstructive microsurgery. The
tissue used from the abdomen
remains as that from the belly-
button to pubic hair and hip
bone to hip bone, but the deeper
dissection is the challenging part.
Blood supply to the skin and fat
comes from perforating vessels off
A
DR. KENDALL
ROEHL, DR. PATRICK
HSU, AND DR.
MELISSA CROSBY
OF MEMORIAL
PLASTIC SURGERY
IN HOUSTON AND
MEMORIAL PLASTIC
SURGERY CLEAR
LAKE IN WEBSTER
TEXAS WERE ALL
TRAINED AT THE
PRESTIGIOUS
MD ANDERSON
CANCER CENTER IN
RECONSTRUCTIVE
MICROSURGERY.
THEY HAVE
OVER 26 YEARS
OF COMBINED
PLASTIC AND
RECONSTRUCTIVE
SURGERY
EXPERIENCE AND
WELL OVER 2000
MICROVASCULAR
FLAPS COMBINED.
THEIR FOCUS IS NOT
ONLY ON BREAST
RESTORATION BUT
PERSONALIZED AND
COMPASSIONATE
CARE AS WELL
AS EXCELLENT
AESTHETIC
OUTCOMES, OFTEN
THE SILVER LINING
OF THE BREAST
CANCER JOURNEY.
“In 2016,
an estimated
246,660 new
cases of invasive
breast cancer are
expected to be
diagnosed
in women in
the U.S.”
Other Abdominal Flaps
SIEA (Superficial Inferior
Epigastric Artery)
DIEP (Deep Inferior
Epigastric Perforator)
Muscle Sparing

3. 2016 MAY/JUNE TxMD 37
Monthly.com
the deeper deep inferior epigastric vessels that arise from the external
iliac artery and vein. These vessels are dissected free, leaving all of the
rectus muscle behind. They are then transected at their take off from
the external iliac vessels and transplanted to the chest. Here they are
attached to the internal mammary artery and vein beneath the bench
press muscle and the underlying rib, but just above the lung. The
blood vessels, the size of a coffee stirring straw, are attached together
artery to artery and vein to vein with sutures the diameter of a piece
of hair using high-powered magnification, either a microscope or
glasses called loupes.
The benefits of performing breast reconstruction using a woman’s
own tissue is a breast that is all their own skin and fat allowing
for texture and movement most like a natural breast, eliminating
the risk of implants and the need for maintenance as well. In time,
these abdominal tissue reconstructions age with the woman, and
symmetry to a non-cancerous contralateral breast is easier to
achieve. Often, the abdomen provides enough tissue for bilateral
reconstruction if the patient opts to have the opposite breast
removed to decrease their risk of a second case of breast cancer or
in the case of bilateral breast cancer. On the abdomen, women gain
the cosmetic benefits of a flatter, smoother, tighter abdomen, and in
a DIEP, they retain their muscle strength and have a much lower risk
of abdominal weakness or bulging, which is often seen in TRAM
and muscle-sparing TRAM surgeries.
Recovery from this surgery usually involves three to four days in
the hospital for monitoring and pain control. Patients have three to
four drains and have to wear a panty-girdle for six weeks.Activity
is limited to lifting 10 to 15 pounds or less for the first six weeks.
Patients often return to work in three to six weeks depending on
their job requirements.
Breast reconstruction is usually a three- to four-step process.After
the initial transfer, patients often undergo a second surgery about
three months later to improve the shape and symmetry of their
breasts and to touch up any scarring on the abdomen. The third step
is reconstruction of the actual nipple, and the last step is to re-create
the pigmented areola, most often done with tattoo techniques.
DIEP flaps and other microvascular breast reconstructions
should only be performed by the most highly skilled microsurgeons
certified by the American Board of Plastic Surgery and members of
the American Society of Plastic Surgeons.
FOR MORE INFORMATION ON MEMORIAL
PLASTIC SURGERY—CLEAR LAKE VISIT
WWW.MEMORIALCLEARLAKE.COM OR CALL
713.609.9335.
FOR MORE INFORMATION ON MEMORIAL PLASTIC
SURGERY VISIT WWW.MEMORIALPLASTICSURGERY.
COM OR 713.633.4411.
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