High-Definition DIEP Flap Q&A With Dr. Gassman
We recently hosted a Facebook LIVE discussing high definition DIEP flap breast reconstruction. If you missed it, don’t worry! You can catch the replay below.
What is high definition DIEP flap?
Something that has been evolving in our practice is how we address the donor site and improve the overall quality of the aesthetic outcome for our patients going through the reconstructive process. We’ve come through to the evolution of the high definition DIEP flap. This is essentially where we’re trying to optimize the donor site, and the aesthetic outcome of the breast as much as possible. To do this, we use a number of techniques that come from the aesthetic world in which we can use the original operations, donor site closure, as well as the techniques for liposuction and fat grafting in the revision procedures to yield an overall improved aesthetic contour.
How does high definition DIEP flap differ from regular DIEP flap breast reconstruction?
Ultimately, the breast reconstruction itself is very similar. The tissues are elevated from the abdominal area, and then brought up to the chest, then connected with blood vessels, and then to nerves as well if they’re available.
Where we start to differ is how we address the donor site. In the right patient, we’re able to actually contour the abdominal wall, so that the overall contour of the belly and hip area is greatly improved. This gives an overall more athletic and toned appearance to the abdominal wall. The differences begin to separate further when we get into the revision period. When we’re doing high volume liposuction, we can do further liposculpture of the abdominal wall, torso, and posterior area add additional fat graft to that reconstruction.
What are the benefits of high def DIEP flap?
Ultimately, the primary benefits are going to be an overall improved aesthetic contour and a much more athletic appearance. This procedure gives a greater contour definition to the abdominal area (six-pack area). Although we do not create an actual six-pack, the overall aesthetic contour of the abdominal area appears much more toned with a greater definition of the patient’s curves.
What determines if you are a candidate for the high def DIEP?
This comes down to the patient’s overall anatomy and health. Some patients have a very good relationship with their overall proportion, the length of their torso, their width, and how thick their abdominal wall is. In the process of closing, if we’re able to put in sutures that allow us to shape that can reveal those curves and the patient would be a great candidate. It adds a very small amount of time to the overall operation, but all in all, it yields an excellent result.
What would be considered an acceptable BMI for patients interested in this procedure?
Most patients that fall below a BMI of 32 would be a considerable candidate. However, the sweet spot falls on patients with a BMI of anywhere from 25 to 30. More often than not, these are patients that are pretty athletic but have trouble losing a little bit of extra weight from the abdominal area. These patients generally lean towards having tissue reconstruction because it solves many issues. In this case, it really just adds the “icing on the cake” if you will.
What will the scar look like?
The scar itself changes somewhat in the original operation. Part of how we do this operation is that we’re able to advance the abdominal wall closure a little bit further. We are able to put in the sutures to help with the closure and push that scar just a little bit lower. Those same sutures are the sutures that add additional definition to the abdominal wall. The overall shape of that scar may change as well because the scar will bend in that lower position to actually also improve the hip contour and silhouette.
What is the role of body contouring in high def DIEP?
They are basically one and the same. Body contouring is a kind of bigger overall umbrella within plastic surgery. High def DIEP is essentially an intersection where high definition body contouring meets breast reconstruction with DIEP. Body contouring can extend much further into other areas and be much more involved, say in patients with massive weight loss and that sort of thing. This is basically a great intersection of these two exciting areas of plastic surgery.
Are all patients able to receive the high def DIEP?
This is decided on a case-by-case scenario. That is a decision you’ll make with your doctor. With the use of additional sutures, we want to make sure that the patient doesn’t have any underlying wound healing risks.
Otherwise, a healthy patient with an appropriate BMI, high def DIEP is a great alternative. However, for those patients that may carry some additional risk factors for wound healing, this procedure may not be ideal. Some things that might put a patient at risk would be smoking, elevated diabetes, and other things like that. This is really something that’s customized and figured out in a case-by-case scenario between the physician and the patient.
How does recovery time differ from the regular DIEP flap?
The overall recovery is pretty much the same. I will say that patients do report a little more tightness in their abdominal wall as you’d expect, but that’s part of how it works.
Does insurance cover high def DIEP flap?
Fundamentally, there isn’t much change in that regard. There’s no additional charging at this point.
How many patients received the high def DIEP compared to regular DIEP?
That is basically determined on an “as encountered” basis. That’s something where I will sit down with the patient and ask what their overall motivations and goals are. I would say a little under 50% opt to have high definition DIEP. It usually depends on their stage of life and if that is something they are interested in at that point.
How does high def DIEP affect stage two?
I’ve been pleasantly surprised that actually doing these techniques on the front end has greatly improved some of the other issues we have had to address in the second stage like dog ears. By no means can I guarantee that they’re gone but they definitely have improved.
In my mind, stage two is something that’s best used to improve elements within the breast itself, but we can use elements of these high definition liposuction and body sculpting when we go in to obtain fat graft for the breast itself.
It’s something that helps set us up in the first stage and we can really get dramatic results by the end of the second stage.
Do skin islands play the same role in high def DIEP as regular DIEP?
Yes, they do. Skin islands are used predominantly to help monitor the flap after we’ve transferred the tissue. The blood flow through the skin shows both good arterial and venous flow, which is critical to what we do. So that’s a very natural and important way in which we can monitor the quality of the vascular reconstruction of what we’re doing.
High def DIEP doesn’t necessarily address that, but it addresses and overall improves the contour of the donor site.
Can you have high def DIEP if you’ve already had stage one?
Yes, it is still a possibility. However, that would be a discussion to have with your plastic surgeon to see if the volume of fat graft that’s required for the secondary procedure, and then when that fat graft is obtained, the total volume that’s required, and where that will be taken from. Based on that we can make decisions on the liposculpture that can be achieved.
What is TruSense℠?
TruSense℠ is where we obtain nerves from the abdominal wall. These are isolated while we’re carefully sifting the blood vessel out from in between the muscle fibers of the abdominal wall.
We take additional time and gain additional length on it. Then once that tissue has been transferred to the chest, the nerve is then found adjacent to the blood vessel in the chest and we make that connection. That connection will not be made if the position of the nerve from the abdominal area would lead to a kink in the blood vessel. The priority there is the blood vessel over the nerve. Wherever possible, we obtain that nerve in the hopes that we can make that connection.
Once that connection is made, it’s then up to the patient’s body to power up that connection, which can take several months, but then goes from having no possibility of sensation to having the possibility of sensation.
If someone had a mastectomy 15 years ago, would they still be a candidate for high def DIEP flap?
Potentially, yes. Ultimately, the important part of the incremental change here is really the donor site. Over the years, we’ve gotten very good at creating a very aesthetic breast and having good abdominal closure. Now we’re progressing the donor site closure that much better and that much further.
How do you get rid of abdominal bloating and swelling post-phase two?
There are many reasons for that. One of the possibilities could be fluid that is retained within the abdominal wall in which lymphatic drainage could improve. That can take some time. It can happen in forms of compression therapy. But otherwise, more often than not lymphatic rerouting just takes a significant amount of time.
Also, on a case-by-case scenario, sometimes depending on where the reconstruction is done, you just need to discuss with your clinician that there was truly a DIEP performed. Sometimes, if there was muscle removed that can lead to some abdominal discomfort.