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.

If you’re planning a single-side mastectomy and breast reconstruction, you probably have plenty of questions about and how your surgeon will make sure your results “match.” You expect your breast reconstruction surgery to restore your shape and some of your self-confidence after your mastectomy, so it only makes sense that your results should look as natural as possible.

Most of the time I will be able to recognize from the beginning when a patient will need to have the other breast lifted or reduced so that both breasts match each other as well as possible, but sometimes I won’t know for sure until she has healed. Here are a few of the most common reasons why you may need follow-up surgery:

• Larger, saggier breasts: Women with very large breasts will often need to have their natural breast reduced. I am able to get very good results matching even larger breasts during breast reconstruction surgery in New York. Sometimes thinner women with larger breasts pose a particularly challenging case, and I may recommend a reduction or a lift with reduction to ensure balance following their procedures.
• Small or unevenly positioned breasts: Many women are happy with a reconstruction procedure that matches a smaller breast, but some will choose their reconstruction as an opportunity to fill out their breast volume on both sides. I have found that the results are usually much better when the patient receives the breast augmentation at the same time as her breast reconstruction on Long Island, New York.
• Downward-pointing nipples: Unless you received a nipple-sparing mastectomy, your initial surgery probably left you without either nipples or areolas on that breast. I can place the reconstructed nipple and areola at any position, but in most cases patients will want some lift to give both breasts a more shapely and perky appearance.

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

The major trend in breast reconstruction surgery right now is toward reconstructing the breast immediately. If you’ve waited some years after your mastectomy before you started to consider breast reconstruction, you might be worried that you’ve missed your chance for this procedure, but I can reassure you that this isn’t the case.

In my experience there are a few clear advantages to having your breasts reconstructed immediately, but there are also plenty of benefits for women who choose delayed reconstruction, and there is no reason to worry that you’ve somehow lost out on your opportunity to benefit from breast reconstruction just because you waited.

Immediate Reconstruction: The Advantages

For most patients, the biggest benefit of having breast reconstruction immediately after mastectomy is that you will wake up from surgery and still have breasts. For most women this benefit alone is a significant reason to have immediate reconstruction, but as a recognized authority on breast reconstruction procedures I can tell you that breast reconstruction has plenty of other benefits even if you wait years for your procedure.

Look at the Bigger Picture

No matter what your age, your breasts can have a profound impact on your self-image and sense of femininity, and that relationship doesn’t change just because your body does. Studies have found that both immediate and delayed breast reconstruction can benefit women in areas such as:

• Body image
• Self image
• Mood, emotion, and positivity
• Sexual satisfaction

Ultimately, the choice to undergo breast reconstruction after mastectomy on Long Island, New York should be yours and yours alone. But I think it’s important for patients not to feel that they have “missed out” on their chance to gain better self confidence and complete the healing process just because it’s been some time since their mastectomy.

Welcome to BreastReconstruction4U, the blog of board-certified plastic surgeon Dr. Alex Keller, specializing in breast reconstruction surgery for women from New York and all over the United States.

DIEP flap breast reconstruction is being sought out by more and more women throughout the country. This type of reconstruction gives a soft, natural breast. Because no muscle is taken, the risk of hernia formation is extremely low. Please feel free to post your comments and questions on this blog.