Recommendations for the Best Reconstructive Surgeons Who Do DIEP

All of our patients get a CT scan prior to surgery to identify the vessels to see if they are a candidate. If very few cases complications can arise in which the connections of the blood vessels do not work and other options for reconstruction are used. 
Seek a board certified plastic surgeon to see if you are a candidate!

Hello!
Most surgeons typically will order a CTA of the abdomen and pelvis prior to a DIEP flap to make sure your vessels are patent in order to perform the DIEP. It’s not 100% guarantee until we start the surgery and start the dissection. But, the imaging is a good baseline.

Hi fjr,
DIEP refers to no muscle being taken up with flap (the abdominal tissue that is transferred to the chest). How much muscle is taken with the flap is an important consideration, but it is not the end-all-be-all. For example, the vertical length of muscle split is related to how many nerves to the rectus muscle are cut. Also, since the muscle receives its innervation from the lateral (outside), a medial row perforator or perforators will have less muscle injury than a lateral row.
I am always looking to do the least injurious operation to your core that will also ensure a flap with enough blood supply. As such, and to answer your question, I can only be sure of the exact plan (SIEA flap, DIEP flap, multiple perforator DIEP flap, ms-TRAM) once I evaluate the perforators and do the operation.
Hope this helps.
Best,Christopher Pannucci MDBoard Certified Plastic SurgeonPlastic Surgery NorthwestSpokane, Washington

Hello!  Thank you for your question.   After radiation, you have an increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area.  The best method to reconstruct a breast following radiation therapy is with a flap.  The flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation issues compounding the problem.  Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today.  As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less.  They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.  It is true that not many surgeons perform this procedure.  There are many options to breast reconstruction including implant-based and flap-based procedures.  The complication rate with implants following radiation is reported as high as 60-70% in some studies.  Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results.  I typically prefer flaps, such as the DIEP flap.  Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast.  Flaps such as those above, including others, are available.  The decision to continue with this will be your decision and what you are willing to go through.  There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you.  Hope that this helps and best wishes!

No, this is not true.  A CT angiogram is very helpful in identifying the size, location and anatomy of the deep inferior epigastric perforating vessels.  

By looking at the study, the DIEP flap surgeon should be able to have a good idea if you are a candidate for a DIEP flap, SIEA flap, muscle-sparing free TRAM flap, or not a candidate at all.

I hope this helps.

You can usually find a small number of plastic surgeons in a major city, often times at an academic medical center, who perform the DIEP operation on a regular basis.   Having a microsurgery fellowship means that the plastic surgeon spent an additional year performing high volume, complex microsurgical cases.  Very often, these reconstructive microsurgeons are members of the American Society for Reconstructive Microsurgery (ASRM) in addition to ASPS.

It is very rare when a DIEP cannot be performed, but it is ultimatley an intraoperative decision as to whether you end up with a DIEP or some variance of a TRAM.   New imaging modalities with CT Angio or Duplex ultrasound can help "map" these vessels and delineate the anatomy better, but there is no guarantee.   Your surgeon will always perform the operation that best suits you and your anatomy, to give you the safest and best result.

If you are looking for a DIEP flap reconstruction, then you really want to go to a surgeon who does alot of them.  This is a surgery that any plastic surgeon should be able to do, but only a small number of us do routinely.   It can be acomplicated surgery, and there are some variables to it, but for the most part, you usually know whether it can be done before hand or not.  This is because there are some great imaging tools, like CT angiogram, that can really show exactly where the blood vessels are, and how big or small they are.  It is an invaluable tool, and something that any one undergoing a DIEP should have done preoperatively.  I hope this helps.

Experienced DIEP flap surgeons usually perform a preoperative CT scan or MRI to map out the blood vessels that will nourish the flap tissue. This facilitates preopertive planning to minimize intraoperative surprises. The DIEP procedure can be performed in almost all cases where there is adequate abdominal excess, with rare exceptions where patients may have had previous abdominal surgery that caused significant scarring. Therefore it is important to seek out a surgeon who is experienced with this technique. 

CT scans are used in my practice to identify blood vessel anatomy that a DIEP flap can be designed upon.  Some of these anatomic differences make it harder to perform DIEP flaps but not impossible.  In almost every instance the blood vessels can be taken out of the muscle with little to no sacrifice of muscle.

IF the plan is to perform a DIEP flap in the majority of cases it is performed. If the anatomy is not conducive to it, some may take a small portion of the muscle to be safer.