Avoiding Denervation of Abdominal Muscles during DIEP Flap Breast Reconstruction
Author: Dr. Minas Chrysopoulo
How can surgeons reduce the risk of abdominal complications following DIEP flap breast reconstruction?
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.
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.
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Christina
I had a bilateral DIEP in 2011 after cancer and BRCA 1 positive. I started having problems with abdominal muscle cramps not long after. Now I have horrible muscle spasms that are so frequent and intense it has become difficult to function at times. The Dr. that preformed the surgery is on the other side of the country so I can’t see him. I don’t really want to after a flap failure, 2 revisions and extra time in the hospital for MRSA. Before the surgery he told me my vessels we small but it would work. Is it a nerve problem? A circulatory problem? GI diagnosed me with IBS C but doesn’t get the spasms. Before the surgery I never had bowel problems. I can’t believe I survived cancer to live like this. I live close to the Cleveland Clinic. What kind of Doctor should I see?
PRMA Plastic Surgery
We hate to hear you are going through all of this Christina! We would recommend following up with your original surgeon to let him/her know what is going on. They may be able to refer you to a surgeon that specializes in abdominal wall repair near you.
Anonymous
If there is denervation of the rectus abdominus muscle during diep flap, resulting in a bulge, can this be “fixed” successfully with mesh?
PRMA Plastic Surgery
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.
Anonymous
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.
PRMA Plastic Surgery
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 https://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!
Patty
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?
PRMA Plastic Surgery
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!
Ros Stone
I had diep flap surgery 5/26/21. I was left with a belly that looks distended as if Im 6 months pregnant. I was told this is because I have diastesis recti. I believe this is possible since I carried twins and told it was seen ok the ct scan but Im very displeased that I wasnt warned this could happen and that the surgeon didnt look for this in the ct scan prior to surgery. He says it can be fixed with plication in phase 2. But how would I know that this bulging is not because of denervation?
PRMA Plastic Surgery
We are so sorry to hear you are experiencing this. Because we are not familiar with your case, we would recommend discussing your concerns with your surgeon and develop a surgery plan for you based on your needs and your result expectations.
Dana
How common is this? I’m looking into doing DIEP but this is a huge turn off… I have young kids, and I’m young, I cannot afford to not have abdominal muscles (not that anyone can).
Are all DIEP microsurgeon trained in this technique to try and save the nerves?
PRMA Plastic Surgery
In experienced hands, like the expertise of the surgeons at PRMA, this is a highly rare complication. The surgeons at PRMA take extra time to spare the abdominal nerve during the DIEP flap to ensure patients are able to maintain core strength long term.
Colette
What are the post op symptoms of diastesis recti? If damaged during Diep,, can this be fixed?
If yes, How complex is it to fix ?
PRMA Plastic Surgery
If you are concerned you may have abdominal strength complications, we recommend following up with your surgeon. In some cases, abdominal core strength exercises can help, and in extreme cases additional surgery may be required. In experienced hands, this is a highly rare complication associated with DIEP flap surgery.
Adria Orue
I had a double mastectomy with DIEP on 4/21/21. One week later, my abdomen started swelling, and they told me that I have denervation of the abdominal wall with atrophy. Can this be repaired? Can this problem could be preventable?
PRMA Plastic Surgery
We would recommend consulting with the plastic surgeon who performed your original surgery. They can evaluate your needs and provide you with surgical recommendations and if needed a referral to an abdominal wall correction surgery specialist.
Kim Mennillo
I had Diep flap surgery in 2017 and am still dealing with midline numbness and swelling from sternum to navel. The numbness I can handle; it’s just an odd feeling if I bump into something. But the bloating and swelling bothers me a lot and I’m wondering if it will ever go away. I asked my surgeon what could be causing it and he said he didn’t know! I don’t believe he wanted to tell me the truth. Reading this article tells me what happened. I just don’t understand the midline swelling. Why is that happening? Scar tissue? Can nerve damage cause swelling? If so, can it be repaired or will that just cause more problems?
PRMA Plastic Surgery
Hi Kim, we are so sorry to hear you have been through so much! Our board-certified plastic surgeons would be more than happy to evaluate your needs and provide you with their medical recommendations upon consultation. Please feel free to give us a call at 210-692-1181 to schedule or complete our virtual consultation here: https://prma-enhance.com/schedule-a-consultation/.
Carol
I had diep flap surgery in 2016 and 3 days later back in for the breast to be removed it was no a success they told me I have had nothing but trouble with my stomach since this was done I have had many scans and ultrasounds they ruled out a lot of things but am on anti acid medication since this happened after 5 years August 2021 I was taken to emergency 1 dr picked up I had 76 in blood gas I had respiratory failure and put in icu I was close to death they told me very lucky to be here and they found I have no stomach mussel on my right side of my stomach that help me to breath through the night and carbon monoxide had built up I’m now on a bipap machine for the rest of my life now is there any advice you could give me on any medical neglect here plz
PRMA Plastic Surgery
Hi Carol, we are so sorry to hear you have been through so much! Our board-certified plastic surgeons would be more than happy to evaluate your needs and provide you with their medical recommendations upon consultation. Please feel free to give us a call at 210-692-1181 to schedule or complete our virtual consultation here: https://prma-enhance.com/schedule-a-consultation/.