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.