DIEP Flap Surgery Best for Natural Breast Reconstruction Results?
- Asked 5 years ago
There's a possibility I may need to have a mastectomy, so I have been looking into which breast reconstruction procedure would be best for giving me the most natural-looking new breasts. I read that the DIEP flap surgery is new and much more expensive than other breast reconstruction surgeries because it gives the best result. Is this true? I want to know which breast reconstruction procedure the doctors think is best?
DIEP Flap Breast Reconstruction Surgery - Natural Breast Reconstruction
DIEP Flaps are when ONLY skin and fat from your lower abdomen are used to reconstruct your breast. No muscle is taken like in the TRAM operation. By avoiding taking muscles, you preserve your core strength. DIEP flaps should be performed by surgeons experience in microsurgical breast reconstruction. DIEP flap breast reconstruction do create natural breasts. The other advantages of DIEP flap breast reconstruction are that the flap will not rupture like implants and will change with you over time.
DIEP Flap breast reconstruction
A DIEP flap stands for Deep Inferior Epigastric Perforator flap. It is an evolution in technique from a traditional free TRAM flap. The main difference is the goal of sparing the muscle from the abdomen to decrease the likelihood of bulging or hernia in the abdomen after the procedure.
DIEP flaps for breast reconstruction are typically covered by your insurance provider. The cost issue arises when a surgeon does not participate with your insurance provider. The higher cost is due to the time and risk of the procedure, not based on the "naturalness" of the reconstruction.
In general, breast reconstruction is a trade-off. Implant reconstruction can have a very natural appearance in the right patient. However, it often requires multiple (though shorter) procedures and the implants themselves may need replacement over your lifespan. Using your own tissue (autologous procedures) via a TRAM flap, DIEP flap, or other tissue provides a reconstruction which is made up of skin and fat that feels more natural. However, the trade off is the longer operation, the risks of complications in the abdomen, and in the case of a free flap (such as a DIEP) the risk that the part or all of the flap may not live.
Breast reconstruction requires a long consultation to properly educate you on your options. I recommend a thorough consultation with your plastic surgeon to review all of your options and to show you photos of the different types of reconstruction available to you.
Web reference: http://www.drbogue.com
DIEP flap Breast Reconstruction and Cost
First, breast reconstruction after mastectomy must be covered by your insurance thanks to a 1998 federal law. This is one procedure insurance companies can't successfully deny. So given the question regarding cost -- this should not be a self-pay cosmetic procedure.
Now to address your question regarding the DIEP flap. The DIEP flap utilizes the excess skin and fat that is normally thrown away in a cosmetic tummy tuck. It is like its predecessor, the TRAM flap that harvested the excess skin, fat, and muscle from the belly. However, unlike the TRAM flap, the DIEP flap specially harvests the skin and fat and spares the abdominal wall muscles. the DIEP flap is an advanced microsurgical tissue transplantation procedure.
Autologous reconstruction such as the DIEP or TRAM flaps generally can be performed without the need of a foreign body implant. Once your DIEP flap has been performed (generally > 98percent success rate), your reconstructed breast is yours to keep. It is your own tissue. There are no risks for foreign body scar tissue formation or implant failure. However, autologous reconstruction requires an incision somewhere else on your body and is more involved in terms of operative time and recovery.
There is no one perfect answer for the "best" reconstruction. It's what is right for your and your own individual goals.
Recent Breast Reconstruction Reviews
Breast Reconstruction Photos
Autologous tissue is most natural
In my San Francisco area practice I have been able to offer my patients a wide range of reconstructive options. I've had the opportunity to co-found a breast reconstruction program and found two microsurgical programs which primarily have focused on breast reconstruction.
The two basic categories of breast reconstruction include implant reconstruction (typically tissue expander followed by a permanent implant) and autologous tissue (using your own body's tissue to reconstruct your breast).
I believe that if you are going to use autologous tissue a DIEP flap (or a muscle sparing free TRAM where some of the rectus muscle is taken) gives superior results to a tradition TRAM (where the abdominal tissue is based on the rectus muscle and remains attached).
Specific benefts of a free TRAM or DIEP operation vs. a pedicled TRAM include:
- Typically able to use more of the abdominal tissue to reconstruct the breast because the microsurgical options typically provide a better blood supply.
- Eliminates the abdominal bulge sometimes present when you turn the TRAM flap (the bulge is created by the attached rectus muscle).
- Better abdominal wall strength with decreased risk of hernia (this is because the TRAM flap sacrifices the entire rectus muscle whereas the DIEP and muscle sparing free TRAM leave the bulk of that muscle intact and functional.
With regard to cost - microsurgical breast reconstruction is a much larger operation. It typically takes me 2-3 hours to perform a pedicled TRAM breast reconstruction. A microsurgical breast reconstruction (DIEP, SIEA, free TRAM, SGAP) typically takes 5-6 hours.
In addition - patient's need a significantly longer recovery time from a microsurgical breast reconstruction and my patient's (and this is typical) stay in the intensive care unit for several days for close monitoring of the microsurgical areterial and venous connections.
While autologous tissue breast reconstructions are significantly more laborious and require greater time to recovery (microsurgical or not), most experts agree that an implant breast reconstruction looks best at about 6 - 24 months after surgery and begins to look worse overtime whereas autologous tissue reconstructions look reasonable about 6 months post-op and improve over the next year and are incredibly lasting in terms of natural appearance.
In addition, using your own tissue has the benefit of being resistant to infection, capsular contracture, implant rupture, etc.
The bottom line is you need individualized review of your options and it should come from a board certified plastic surgeon who performs ALL types of reconstruction - so you get a non-biased answer.
Interestingly, in terms of numbers, if you look at all comers most people get breast implant reconstructions likely because many surgeons don't perform microsurgical breast reconstruction and because insurance compensation is better for implant reconstruction (in terms of compensation vs. amount of work - no one would argue that implant reconstruction is more laborious than microsurgical breast reconstruction). If you isolate cost as a factor (ie look at university programs or centers of excellence where insurance compensation may not be as large a factor) many more people get autologous breast reconstruction, likely because of the superior results.
Please do not hesitate to contact my office if you have additional questions regarding breast reconstruction.
Natural Appearing Breasts with Added Benefits
You are absolutely right that a DIEP flap produces the closest tissue match to native breast tissue. Breast tissue primarily consists of skin and fat, as does the DIEP flap.
As far as cost, breast cancer reconstruction is covered by law under health insurance. So please do not base your surgical decision on cost. Most breast reconstruction surgeons can work with your insurance company to obtain coverage.
The primary benefit of the DIEP flap are the "Added Benefits". Abdominal musculature and fascia are preserved, which allows maintenance of abdominal core strength and function. In comparison to the TRAM flap (rectus muscle removed), the rate of hernia formation is almost negligible with a DIEP flap.
If you are considering a DIEP flap, I highly recommend that you find a Board Certified Plastic Surgeon with a practice focus and extensive experience in the DIEP flap technique.
Web reference: http://www.drpaulgill.com
Your own tissue is better than an implant usually
In general, using your own tissue makes for a more natural looking and feeling breast but at the expense of more scars and a much longer recovery than from implant reconstructions. This is especially true in radiated patients and in one sided reconstructions. Bilateral reconstructions without radiation can be performed adequately with implants.
I personally favor the free TRAM because it has a stronger blood flow than the DIEP flap and minimal difference in functional abdominal compromise. Also, you only get to do these operations ONCE so if you do the DIEP and it fails, you can't go back and do a free TRAM later.
DIEP FLAP SURGERY
A free flap breast reconstruction is more expensive than a pedicled TRAM or tissue expander- implant recosntruction. Some surgeons charge more for a perforator flap reconstruction than a free-Tram. I prefere autologous tissue reconstruction over a tissue expander and implant. I think it gives a more natural appearance and feel.
DIEP flap can give a very natural look for breast reconstruction
When done properly, the DIEP flap can give a very natural look for your breast reconstruction. The surgery uses your own tissue and ages with you over time. If you gain weight, they get bigger; if you lose weight they get smaller. With successful surgery, you will not have to ever worry about getting an implant changed.
See a skilled plastic surgeon in your area who has extensive experience performing DIEP flap surgery. I am in Nashville, TN and have a greater than 99% success rate with the DIEP flap.
Web reference: http://www.drjjwendel.com/index.cfm/pageid/17172
Is DIEP flap the best method of breast reconstruction.
Unfortunately, the hype on the DIEP flap has never been proven in a scientific study. The TRAM, muscle sparing free TRAM, and DIEP are all basically the same operation along the same spectrum...transfer of the lower abdominal skin and fat. The difference is how much muscle is removed. The DIEP flap advocates claim worlds of difference between the DIEP and other methods of reconstruction. The truth is there has never been a study to show a signifcant difference in ability to perform every day activities after one year, no matter what method is used. Furthermore the DIEP tends to have more fat necrosis than other free flap methods. The best method is really dependent on your individual situation and anatomy. A well qualified reconstructive breast surgeon should be well versed in all methods and be able to go over them with you so you can make an educated choice.
DIEP flap - excellent option for breast reconstruction
With the advent of microsurgical perforator flaps, this form of reconstruction has revolutionized plastic surgery. Along with them, the application in breast reconstruction has been tremendous. By the replacement of the skin and soft tissue that is removed during the mastectomy with viable, well-vascularized, excess skin and soft tissue from the lower abdomen, a beautiful breast reconstruction may be achieved that is completely your own tissue. This Deep Inferior Epigastric Perforator (DIEP) flap has gained much notoriety for breast reconstruction today.
The tissue is taken from the lower abdomen, much like that removed during a tummy tuck. Utilizing the excess tissue from this area and hiding the incision low on the abdomen, well-hidden within the panty line, the donor site is an excellent option for borrowing tissue for a breast reconstruction. This skin, fat, and soft tissue, along with its blood supply is taken and moved into the breast area. These small blood vessels are then reattached via assistance of a microscope to vessels in the breast area. This tissue is then shaped and molded to reconstruct an aesthetically pleasing breast reconstruction.
With this new advent of perforator flap techniques, it is the most innovative and state-of-the-art technique used today in breast reconstruction, let alone plastic surgery as a whole. Unlike the traditional way of reconstructing a breast utilizing this tissue (aka TRAM flap), the DIEP spares the muscle of the abdominal wall, by carefully dissecting the blood vessel from within the abdominal musculature and leaving the muscle in place. This muscle-sparing, perforator flap type of reconstruction is beneficial for these reasons. There is less donor site morbidity from the abdomen, since the muscle is left intact. Along with that, there is less postoperative pain. The function of the muscle remains, so abdominal wall integrity remains intact and there is less chance of hernias or bulges, since the muscle remains. These problems are much increased with the conventional TRAM flap, but unlike it, the aforementioned benefits are obtained with the DIEP microsurgical free tissue transfer breast reconstruction.
Unlike conventional TRAM flap reconstructions, use of our refined perforator flap techniques allow for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast the contour of the abdomen is often improved much like a tummy tuck. This well-vascularized flap reconstruction also is also completely your own tissue, and often resembles, moves, looks, and feels more like a natural breast than reconstructions using implants. Other perforator flaps used for breast reconstruction include the SIEA (Superficial Inferior Epigastric Artery), SGAP (Superficial Gluteal Artery Perforator), IGAP (Inferior Gluteal Artery Perforator), and TAP (Thoracodorsal Artery Perforator) flaps, among others.
If you're interested in an advanced reconstructive procedure as such, very few surgeons have been trained to perform these and even fewer offer these procedures due to its complexity and skill involved. It may be difficult to find an experienced surgeon to perform this type of surgery with many patients, unfortunately, having to travel away to obtain such reconstruction.
Web reference: http://www.albertandresmd.com
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.