Investigating Options following Necrosis - is diep flap the best option? (photos)

Question

I had necrosis following a breast reduction and lift which left me with extensive scarring on the lower pole of one breast and the breast is smaller than the non-scarred breast. I have since undergone another procedure to excise, close and remove the damaged skin, and because of the damage, my dr had to do a full thickness skin graft. Unfortunately, the majority of the graft failed. Is a Diep-flap my best option at this point?

Gary M. Horndeski, MD · Answer

Diep flap is useful to provide volume as well as surface area of skin and in your case reconstruction.  Your volume loss may be minor and can be corrected by fat transfer.

Best Wishes,

Gary Horndeski, M.D.

Finny George, MD · Answer

Hi, thank you for sharing your question. Based on the photos, your skin should make a significant recovery. You may be left with a noticeable scar but it will be hidden under the majority of your breast tissue. A DIEP flap is likely not your answer. If you have a significant volume difference between the breasts, fat grafting may be a good solution. I hope this helps.

Christopher Pannucci, MD, MS · Answer

Hi TJ73,
DIEP flap is a belly-based free tissue transfer that is typically used to reconstruct the entire breast mound. It brings up excess skin and fat from the abdomen, with a blood supply, for whole breast reconstruction.
Picture #4 looks like the full thickness skin graft had 100% take, converting the open wound of picture #3 to a closed surgical wound (albeit with a color difference and contour difference). 
I would definitely suggest seeing your plastic surgeon regularly. The skin of the reduced breast tends to stretch out over time, and it may be possible to eventually remove the skin graft (potentially in a series of operations) and close skin-to-skin. A DIEP flap would not be your best option to replace skin only.
Hope this helps.
Best,Christopher Pannucci MDBoard Certified Plastic SurgeonPlastic Surgery NorthwestSpokane, Washington

Samuel Lin, MD, FACS · Answer

Thank you for sharing your experience. I would continue to followup with your surgeon regarding next steps related to the area. DIEP flap breast reconstruction usually is in the setting following mastectomy for breast cancer treatment.... all the best..

Daniel Barrett, MD · Answer

Dear TJ73,
I understand your concern. However, without a proper assessment, it would be difficult to determine what went wrong. It is best that you visit your plastic surgeon for further assessment or ask for a second opinion. Only after a thorough examination, you can get proper recommendations and advice.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Ram Kalus, MD, FACS · Answer

Without examining you in person it it difficult to make a specific recommendation for how to best proceed with improving your situation. That said, it is usually advisable to delay any major reconstructive surgery including a DIEP flap until further healing has completed. The wound represents ischemia (poor blood supply) and this is usually deeper than just the skin. An examination would determine if more debridement is indicated before one can expect further healing. If you have lost confidence in your surgeon please seek the advice of another board certified plastic surgeon. Best of luck.

M. Shuja Shafqat, MD · Answer

Good afternoon,
You would need to be seen in person to evaluate. However, I would typically not recommend a DIEP flap for this problem. A DIEP flap is used to reconstruct an entire breast after mastectomy. It would be too much surgery for this problem. In addition, your insurance would not cover that surgery. 
There may be other options but you would need to be seen in person to evaluate. Best of luck!

Derek Fletcher, MD · Answer

I am sorry you had a significant complication after your breast reduction and revision procedure. I strongly recommend allowing your breast scars to mature for a full year (from the time that they were completely healed after the last operation) prior to planning a balancing procedure. Future surgery must address residual skin and tissue shortages. As the scars mature and the skin stretches, the shape of your breast will improve significantly. Sometimes the scars and skin recover enough to avoid skin replacing procedures like a DIEP flap or latissimus flap. If, at the one year time point, you no longer need a skin replacing procedure, you are a candidate for much less complicated operations like fat grafting or placement of a small implant to restore volume and improve symmetry.

Aleksandr Shteynberg, MD · Answer

Hello TJ73. 
Very sorry to see your complication. 
There are appears 2 issues to address: 1. wound/scar, 2. decreased volume
If the wound is still open I usually apply artificial collagen-based based grafts first and in a week or 2 split-thickness graft. In my experience, these technique allows for optimal healing and improved quality of skin graft. 
Once the wound is healed, a fat transfer may be used to increase the volume. 
An alternative plan may be to allow everything to heal and then do a revisionary surgery to excise scars, revise and improve the shape of the side with a complication and perform symmetrizing reduction on the other side. 
DIEP flap is a very big and very technically advanced surgery, but it will provide skin and missing volume in one surgery. Other types of flaps may be considered as well. 
Best. 
A. Shteynberg, M.D. F.A.C.S.Diplomate, American Board of Plastic SurgeryNew York, NY.

Investigating Options following Necrosis - is diep flap the best option? (photos)

Answers (9)

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