Not all DIEP flaps are created equal. The dissection of a DIEP flap requires the selection of the appropriate perforator blood vessels to supply and drain the tissue of blood. Any perforator or combination of perforators may not supply enough blood to drain the flap adequately to prevent fat necrosis (tissue death). So how is the “right” perforator selected? Blood flow to many flaps and to the DIEP flap is axial. That means that there is a dominant direction from which the piece of tissue gets its blood supply. Additionally, size matters. Flow is proportional to the 4^th power of the radius. In layman’s terms, a vessel with one half the diameter has 1/16^th the flow. The venous return is particularly sensitive to size because it is a low pressure system. So we need a large perforator in the right location. Some perforators directly join with the large superficial veins. These perforators are particularly good at draining a flap.

So how do I choose the “right” perforators and minimize fat necrosis? I use an acoustic Doppler to identify the perforators and mark their location on the skin the night before surgery. I use the results of a CT angiogram to understand the size, course and communication with other vessels to further narrow down my perforator selection. Lastly, I use my clinical judgment. Having performed over 1000 DIEP flap breast reconstruction procedures, I have an understanding of the anatomy, interrelationships, and artistry to harvest a DIEP flap with an excellent blood supply to create a soft, natural breast.

This post addresses three common questions my patients have following breast cancer reconstruction:

1. Will breast reconstruction hide other tumors that may later appear in the breast tissue?
2. Will breast reconstruction encourage the growth of new cancerous cells?
3. Should I continue with regular mammograms and breast self-exams?

Does breast reconstruction hide subsequent tumors?

During a mammogram, implants can occasionally interfere with obtaining a good picture, so your technologist must be trained at positioning the implant to enable the best possible image. In a flap reconstruction, the mammogram image may reveal surgical clips or scars, or the breasts might appear fatty, but an experienced technologist will be able to detect any abnormality. Breast reconstruction rarely, if ever, hides a return of breast cancer, so you shouldn’t consider this a significant risk when deciding to have breast reconstruction after mastectomy.

Will breast reconstruction encourage the growth of new cancerous cells?

No research has shown that reconstruction, either with implants or tissue flaps, increases the risk of the breast cancer returning or of a new cancer forming.

What about mammograms and breast self-exams?

After your reconstruction, whether it involves implants or tissue flap reconstructions, it is important to have regular mammograms at an experienced facility. I also encourage you to keep performing breast self-examination on both breasts as soon as you are fully healed from your surgery. This will enable you to notice and report any changes you feel. You should expect your reconstructed breast to feel different, and your doctor or nurse can help you understand the changes.

One year ago DIEP flap breast reconstruction became available at Huntington Hospital when Drs. Keller and Yoon-Schwartz joined the staff. DIEP flap breast reconstruction utilizes sophisticated microsurgery to reconstruct the breast after a mastectomy from excess abdominal fat. As a side benefit, the patient also ends up with a tummy tuck. The result is the most natural and soft breast reconstruction available. Unlike other techniques, the abdominal muscles are not sacrificed. Dr. Keller has been a pioneer in this type of reconstruction and has been performing DIEP flap breast reconstruction for over 15 years.

There are very few places in the country where this type of reconstruction is available. Huntington Hospital is now on that list and is the only hospital in Suffolk County where this procedure is available. Huntington Hospital has made the commitment to support this service by purchasing a new operating microscope that is ideal for successfully performing this procedure.

Over the last year I have done over a dozen DIEP flap breast reconstructions at Huntington Hospital, NY.  This is a relatively small Hospital that gives excellent care. The hospital has made the commitment to purchase a new microscope that will be perfect for the DIEP flap microsurgery required.  This will allow me to perform the procedure more efficiently.  Prior to my arrival this procedure was not performed at this hospital.  Patients who wanted breast reconstruction either had a TRAM flap or implant based breast reconstruction

With so many techniques available for breast reconstruction after mastectomy, you may be having some trouble figuring out which option would be best for you. This post is all about “flap” procedures. At my breast reconstruction practice on Long Island, New York, I carefully evaluate each patient and we decide together which procedure technique will work best.

Flap Procedure Basics

Flap-type procedures (unlike implant-and-expander surgery) use your own skin, muscle, and fat to reconstruct your breast. The tissue can be taken from different areas of the body (the abdomen, back, or buttocks), but the biggest difference between flap procedures lies in how the surgeon will supply this “flap” of tissue with blood flow to keep it healthy.

• With TRAM flap procedures the breast reconstruction surgeon removes or repositions a piece of upper-abdominal muscle tissue containing blood vessels to divert blood flow to the tissues.
• With DIEP flap procedures no muscle is removed; the surgeon only takes a few blood vessels from the lower abdomen and uses microsurgery to connect the tissues to a healthy blood supply.

TRAM vs. DIEP: How They Measure Up

1 - Tissue health:

This factor is absolutely essential for good results; in order for your new breast tissues to live, they need a healthy blood supply to nourish and maintain the cells.

• TRAM flaps usually use upper-abdominal muscles that aren’t ideal to nourish the flap. Taking the muscle along with the vessels makes this procedure faster, but it also means the surgeon is taking blood vessels that carry less blood, which can make it more difficult for the flap tissues to thrive.
• The DIEP flap utilizes blood vessels from the lower abdomen, and connects them to the flap’s own blood vessels through microsurgery. This takes a bit of time, but it means better blood flow, better tissue health, and lower complication risk.

2 - Muscle functionality:

Your abdominal muscles help hold your internal organs in place. Removing part of this muscle sometimes may cause your internal organs to press forward through the gap in the muscle (a hernia), making a bulge that looks (and feels) uncomfortable.

• TRAM flaps, especially the Free TRAM Flap, pose a clear risk of hernia. Healing times are also longer and less comfortable, since the surgeon has to cut into muscle directly.
• The DIEP flap addresses only the skin, fat, and blood vessels while leaving the muscles intact, so recovery is fast and there’s no risk of hernia.

I’ve had over 20 years of experience performing breast reconstruction for patients from New York and all over the US, and I strongly believe that flap-type reconstructions offer my patients much better results than breast implant procedures would.

Implants vs. Flap Procedures: The Facts

To the body, breast implants are still a foreign substance, and they just can’t integrate with your body the way the fat and muscle used in flap procedures would. Complications of implants include:

• Capsular contracture - the body forms an unusually thick layer of scar tissue that squeezes and puts pressure on the implant
• Rupture of the implant shell
• Development of problems like the “bottoming out” and the “double bubble” deformities

Breast reconstruction surgery using implants can also pose extra challenges that some surgeons just aren’t used to dealing with. A mastectomy is bound to leave behind scar tissue, and in many cases will remove part of the pectoral that normally helps cover the implant and help it keep its position. Patients frequently come to my Long Island, New York practice to revise failed implant-type reconstruction, and in many cases part of the problem stemmed from the fact that their surgeons were not using techniques that take into account the special needs of reconstructive patients.

Flap-type breast reconstruction surgery, such as the DIEP flap procedure, avoids these problems because there is no implant, and the tissues used in the reconstruction are your own. Breasts reconstructed using this method look and feel like natural tissue because they are natural tissue.

… So, Why Aren’t All Breast Reconstructions Flap Procedures?

The basic answer is that these procedures are highly complex.

Flap surgeries require a high level of skill to perform correctly, and most surgeons’ training and experience leans much more heavily toward implant procedures. With flap surgery, the biggest challenges are to shape the breast in ways that balance well with the patient’s body, and to create a reliable blood supply to keep the reconstructed breast tissues healthy.

From a surgeon with genuine experience and authority in this area, this isn’t a problem – I’ve never had a patient go home from the hospital and experience flap failure. However, these aren’t surgeries that any “average” plastic surgeon can perform.

Helpful Resources:

• Questions to ask your New York breast reconstruction surgeon
• Details about breast reconstruction
• More information and case studies on implant-type breast reconstruction after mastectomy