Are You A DIEP Flap Candidate?
By: Dr. Minas Chrysopoulo
The DIEP flap procedure has rapidly become the "gold standard" in breast reconstruction. While not every woman is a DIEP flap candidate, many are turned away when in fact they needn't be.
Typical misconceptions include:
1. Previous Abdominal Surgery - While some types of previous abdominal surgery can make the DIEP flap procedure impossible to perform, most of the time previous abdominal surgery really isn't an issue. Many women these days have had a previous c-section or hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery, but this is rare. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having the procedure. If your surgeon is worried about potential damage from previous surgery then certain tests can be performed to examine the anatomy more closely. This can include a simple doppler ultrasound exam in the office or a more involved test like a CT angiogram.
Women that have had a previous TRAM flap, tummy tuck or very extensive abdominal wall surgeries (like complex repairs of huge hernias) cannot have a DIEP or SIEA flap reconstruction because the lower tummy tissue that is needed has already been removed, disconnected or moved around.
While most previous abdominal surgeries may not prevent DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and even hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery.
2. An umbilical hernia - It is exceptionally unlikely that an umbilical hernia would prevent DIEP flap surgery. Most umbilical hernias are small. A very large umbilical hernia can make the surgery harder but even this is not usually a contra-indication to having the procedure.
3. Previous Chest Radiation - One of the most important things for the reconstructive surgeon to achieve is to replace the damaged, firm irradiated tissue with normal, healthy, soft tissue. If the irradiated tissue is not healthy enough to be used as part of the reconstruction (as is the case in many instances), it will be removed and replaced by the healthy DIEP flap tissue.
I have visited with a fair number of patients who have previously been told they are not candidates for DIEP flap reconstruction because they received chest radiation after their mastectomy. That's not the case. Healthy tissue (like a diep flap) is by far the best reconstructive option after radiation.
Most of the time this misconception seems to stem from fear that the radiation may have caused damage to the internal mammary vessels in the chest. These are the blood vessels that are usually used to connect the DIEP flap to the chest. In reality it is very rare for us to find these blood vessels are damaged to the point they cannot be used. In instances where the internal mammary blood vessels cannot be used for whatever reason, other blood vessels can be used instead (eg internal mammary perforators or thoracodorsal vessels).
4. Not the Right Amount of Tissue - You don't need to be overweight to be a candidate for a DIEP flap. What matters is the distribution of the fat. We have performed DIEP flaps on smaller breast, thin women with a BMI (body mass index) of 20 (and even less) because the fat that they did have was "in all the right places". Unfortunately, many women are erroneously told they do not have enough abdominal tissue for a DIEP flap reconstruction by surgeons who do not have adequate experience with the procedure. There is also an upper limit beyond which the risks of surgery typically outweigh the benefits - At PRMA we set an upper BMI limit of 40. Research performed at PRMA has shown that performing the procedure on women with a BMI over 40 significantly increases the risk of complications (especially wound healing problems).