DIEP Flap Vs. LAT Flap for Least Loss of Muscle Strength?

Thank you for your question!  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.

The beauty of the DIEP flap is that it is supposed to leave your rectus muscle untouched.  Unfortunately in my opinion too many surgeons cut the muscle or nerves to the muscle during the procedure thus weakening the muscle sometimes to the point that the procedure is no better than a Free TRAM procedure.

Without knowing any details of your specific case, the best way to avoid compromizing muscle function in breast reconstruction is with an implant. Often the use of an acellular dermal matrix such as Alloderm is helpful. If you have had radiation treatment, then a flap procedure might make the most sense but in general your quickest recovery time and least effect on function uses an implant.

There is a major difference between the latissimus and the DIEP flaps, and that is the incorporation of muscle in the flap. While it is true that there's usually no discernible muscle weakness after a latissimus flap when doing regular activities, one of its drawbacks is the possibility of animation when the muscle contracts.
The DIEP flap however, is fatty tissue only without the muscle. During the procedure there is an incision made in the fascia, and the muscle fibers are split to dissect out the blood vessels needed for blood supply to the flap. Most patients regain normal core strength and muscle strength after recovery. 

Three
basic forms of breast reconstruction exist. You can use your own tissue,
implants or a combination of the previous two techniques. Your own tissue can
be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting.
Implants can be done in one stage or two stage. Two stage reconstructions are
started by placing expanders at the time of mastectomy. Once they expanders are
placed they are able to be inflated as determined by wound healing. The final
time consists of combining any of the above techniques.



If
you are interested in being seen in Austin please give us a call. I know
this is a difficult time for you. The majority of my practice is devoted
to reconstruction for women with breast cancer or who are BRCA+

There are many options for reconstructing your breasts. Each option has its advantages and disadvantages. DIEP, if performed by an experience microsurgeon who knows what they are doing, will not cause you to lose strength and result in abdominal weakness. Unlike TRAM procedures where your rectus abdominus muscles are sacrificed during the reconstruction, this does not happen with DIEP procedures. Lattisimus muscle reconstructions can be considered a hybrid between autologous and implant reconstructions. The volume from the reconstruction comes from implants, but you own autologous tissue from your back is recruited to try and mask the implants and make it feel more like your own. Given the advances in reconstructive techniques, we are able to create natural looking breasts with both implants and alloderm or with autologous tissue. It is best to discuss your options with a experienced plastic surgeon who is experienced with breast reconstructive procedures and decide which option is best for you.

A DIEP flap, if successful, is vastly superior to a Latissimus Dorsi flap in Breast Reconstruction. Using the LD flap involves a visible back scar, needs to be used along with a breast implant and is associated with weakness in pushing oneself out of a deep chair. A DIEP flap is not associated with muscle weakness, the need for a breast implant and has a much more acceptable scar than the one associated with LD flap breast reconstruction. HOWEVER - performing a DIEP flap requires specialized microsurgical skills and not all insurance companies cover these procedures. 

Peter A Aldea, MD
Memphis, TN

Lat. flap is an easier option for the surgeon and patient but not comparable in the donor site scar and muscle loss to DIEP. You will get have scar over lower abdomen that easily cover in comparison the back scar. The other concern with the Lat. flap is the lateral fullness and need for implant. If your surgeon feel more comfortable with Lat.,do not push him/her to do other flaps that are more complex and need micro surgery. DIEP is a difficult flap and not plastic surgeon are trained to do it. 

A DIEP flap is a muscle-sparing procedure that utilizes your excess skin and fat in your lower abdomen to reconstruct your breast.  It saves your abdominal wall muscles (rectus muscles).  There is no need for an implant to reconstruct your breast. 

The latissimus flap takes the muscle skin and fat from your back to help reconstruction your breast in conjuction with an implant.   Although the latissimus procedure takes the entire muscle, studies have shown that there are no long term functional or strength defecits to the shoulder after this procedure.

Hope this helps.