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.

Every breast cancer patient I have met remembers the exact moment she learned of her positive diagnosis, the moment her life changed. Following diagnosis, it’s difficult to think of anything else, and it’s common to feel angry, resentful, confused, depressed, or extremely emotional.

If you or a loved one has been diagnosed with breast cancer, I encourage you to participate in a support group because doing so can benefit your mind, body, and spirit. Research has shown that those who actively pursue the companionship of others with breast cancer can decrease stress levels and boost their immune system.

In a support group, you will learn about and from others’ experiences, discussing everything from mood swings to side effects, sleep disturbances to alternative and advanced therapies. Most importantly, you will discover that you’re not alone.

Support groups can meet in person or online. To locate a group in your area, contact local hospitals or breast cancer clinics, or one of the following organizations:

• The National Cancer Institute’s Cancer Information Service, 1-800-4-CANCER (1-800-422-6237)
• Local chapters of the American Cancer Society and Susan G. Komen for the Cure

For those who live in remote locations or prefer an online support group, many resources are available, including the Breast Cancer.org discussion forums. If you are considering mastectomy, the DIEP Sisters Web site provides an excellent resource for support. It also discusses alternative methods of breast reconstruction after mastectomy, focusing on the DIEP flap.

In my own office, the DIEP Flap Support Group was formed over 13 years ago because many patients had a difficult time finding other people to talk to who had undergone the same surgery. Meetings are held once a month, in a very positive mood and setting. Most members are willing to speak to patients considering the DIEP flap for breast reconstruction, so if you’re interested, phone my office at (516) 482- 1100.

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