Avoiding Denervation of Abdominal Muscles during DIEP Flap Breast Reconstruction

By: Dr. Minas Chrysopoulo

Blogs
November 18, 2008

The following interesting article was published in the "Plastic and Reconstructive Surgery" journal.

Avoiding Denervation of Rectus Abdominis in DIEP Flap Harvest II: An Intraoperative Assessment of the Nerves to Rectus by Rozen W, Ashton M, Kiil B, et al.

Plastic and Reconstructive Surgery:Volume 122(5) November 2008 pp 1321-1325.

Background: The deep inferior epigastric artery perforator (DIEP) flap aims to reduce donor-site morbidity by minimizing rectus muscle damage; however, damage to motor nerves during perforator dissection may denervate rectus muscle. Although cadaveric research has demonstrated that individual nerves do not arise from single spinal cord segments and are not distributed segmentally, the functional distribution of individual nerves remains unknown. Using intraoperative nerve stimulation, the current study describes the motor distribution of individual nerves supplying the rectus abdominis, providing a guide to nerve dissection during DIEP flap harvest.

Methods: Twenty rectus abdominis muscles in 17 patients undergoing reconstructive surgery involving rectus abdominis (DIEP, transverse rectus abdominis musculocutaneous, or vertical rectus abdominis musculocutaneous flaps) underwent intraoperative stimulation of nerves innervating the infraumbilical segment of the rectus. Nerve course and extent of rectus muscle contraction were recorded.

Results: In each case, three to seven nerves entered the infraumbilical segment of the rectus abdominis. Small nerves (type 1) innervated small longitudinal strips of rectus muscle, rather than transverse strips as previously described. There was significant overlap between adjacent type 1 nerves. In 18 of 20 cases, a single large nerve (type 2) at the level of the arcuate line supplied the entire width and length of rectus muscle.

Conclusions: Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.

Some thoughts...

For DIEP flap surgery to be considered successful, several things need to occur:

1) the tissue (flap) transferred to the chest to create the new breast must survive fully.

2) the patient must not suffer any ill-effects from removal of the tissue ("flap") from the abdomen. This is known as "donor-site morbidity". Potential abdominal complications include bulging ("pooching"), a hernia, and significant loss of core muscle strength.

3) the patient must be happy with the results in terms of recovery, return to normal activity and cosmesis.

This article addresses number 2. Ideally, other than the visible scar, the patient's abdomen must recover completely from the surgery, have an aesthetic contour, and suffer no long-term problems to be deemed a full success. Merely preserving abdominal muscle will not guarantee full recovery. It does not matter how much muscle is saved if the nerves supplying it have all been cut. A muscle without a healthy nerve supply will lose it's tone, strength and function. If the DIEP surgeon does not take great care to identify and preserve the majority of the nerves supplying the abdominal muscle then the benefits of the DIEP flap procedure are potentially lost, and the risk of abdominal complications, especially an unsightly bulge, increases. 

Learn More About DIEP Flap Breast Reconstruction

8 Comments

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  • PRMA

    If there is denervation of the rectus abdominus muscle during diep flap, resulting in a bulge, can this be “fixed” successfully with mesh?

    Reply
  • PRMA

    Denervation of the rectus muscle during dissection of DIEP flaps is a not uncommon due to individual patient variation regarding location of perforators that are necessary for flap perfusion. At PRMA, if we encounter this anatomic limitation that obligates us to divide a motor nerve supplying the rectus muscle, we will directly repair the nerve under microscopic magnification in order to optimize the potential for muscle re-innervation during the healing process. If rectus muscle denerevation persists causing muscle weakness and a subsequent bulge, the area of muscle weakness can be “reinforced” passively with various kinds of mesh. The objective during these repair procedures is to promote formation of a thick layer (or sheet) of scar tissue over the weakened muscle so as to prevent bulging of the abdominal musculature with physical activity.

    Reply
  • PRMA

    I had diep on rt. side, m/s free tram on left side (and mesh used on left side). Result: 5 mos. post op and I have a bulge on the diep side, no bulge on left side where mesh was used. Bulge is very small when I wake up but gets larger as I go about my day. Hernia was ruled out via Ultrasound. Can my bulge be fixed by opening up the abd. scar and putting in mesh? Does insurance cover this? or is it considered cosmetic? If it’s cosmetic roughly how much might I expect to pay. Very upset with my outcome as there are other issues, too numerous to mention here.

    Reply
  • PRMA

    I am so sorry to hear you are experiencing this. It is truly difficult to say what your options may be and if insurance will cover it or not until one of our surgeons has consulted with you in person to see what is going on and what may be an option to help correct the complication. You are welcome to fill out our free virtual consultation form at http://prma-enhance.com/patient-forms/virtual-consultation. Once received, one of our board certified plastic surgeons can review your case and provide you with their recommendations. Hope this is helpful!

    Reply
  • PRMA

    And yet a patient, at a well known prestigious practice developed severe denervation. As you said, it can happen. I got that. However, simply pacing mesh on the site will not correct this. As proven by her repair, again at the prestige practice. It recurred. Then told nothing could be done. But that’s not true. Hence where I stepped in and led her to, two very skilled surgeons in NY, that have repaired her, and numerous others with a proven technique and, although told she will live with denervation forever, she at least has had the hernias repaired, no longer a “bulge” and it is holding now. The repair technique is or, soon to be published in The Atlas of Abdominal Wall Reconstruction, Vol. 2. More surgeons need to get on board with this repair technique as too many women are developing hernias after the TRAM Flap, “type 2 free tram flap” and even the famous DIEP Flap. I’m loosing count of how many referrals I’ve made for repair of these surgical complications. It’s bad enough to go through breast cancer, but at what cost? One patient is too many, as they have to live their lives forever damaged. Will not mention practice as that would be prohibited, and defamation. For those living with this, their is a long proven repair. If your practice interested in this repair, feel free to contact me. I’m one….repaired in 2013, and holding.

    Reply
  • PRMA

    Thanks for sharing Tori! So glad to hear your sweet friend is doing better. We will keep our eye out for the publication

    Reply
  • PRMA

    I had DIEP flap surgery in August 2010. something strange has started happening recently. Sometimes when I bend over and my abdominal muscles are contracted, they start spasming like I am getting a cramp in the muscle. I don’t have feeling there so it isn’t painful just weird. Is that common?

    Reply
  • PRMA

    Hello Patty! Seeing as it’s been almost six years since your surgery it is probably best to follow up with your surgeon just to make sure you are not experiencing any complications. It is probably nothing to be concerned about, but it is always important to follow up. Hope you have a wonderful day!

    Reply
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