Recommendations for the Best Reconstructive Surgeons Who Do DIEP

Also Is it true that doctors do not know in advance if they can do a DIEP reconstruction until they get inside?

Doctor Answers 11

Choosing a surgeon for DIEP flap surgery

Most plastic surgeons do not perform DIEP flaps (or other methods of perforator flap breast reconstruction) because of the complexity of these surgeries. In fact, most plastic surgeons do not routinely perform these or other types of perforator flap breast reconstruction even if they perform microsurgery.

The best success rates and the highest degree of efficiency are achieved when these reconstructive procedures performed by a team of experienced microsurgeons. 

If you are considering perforator flap breast reconstruction, you may want to find out more information about your doctor’s experience with these procedures. Here are some useful questions to consider asking:

  • Are you certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada?
  • Have you had additional training in microsurgery and perforator flap breast reconstruction after residency? 
  • What types of breast reconstruction do you most commonly perform?
  • How many DIEP flap procedures have you performed?
  • How many DIEP flap procedures did you perform last week/month/year?
  • How often do you convert a DIEP flap to a free TRAM flap?
  • What is your sucess rate?

It is also a good idea to review a significant number of postoperative photographs of the surgeon’s patients who underwent perforator flap breast reconstruction. This will help you to get a sense of what reconstructed breasts look like and to know more about your doctor’s results in particular.

Likelihood of DIEP flap reconstruction

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. 

Aldona J. Spiegel, MD
Houston Plastic Surgeon
4.6 out of 5 stars 7 reviews

Recommendations for the best reconstructive surgeons who do DIEP?

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!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 26 reviews

Pre-operative planning for DIEP Flap Surgery

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.

J. Jason Wendel, MD, FACS
Nashville Plastic Surgeon
5.0 out of 5 stars 183 reviews

DIEP flaps

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.

Find a plastic surgeon who has done a fellowship in microsurgery.

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.

Charles K. Lee, MD, FACS
San Francisco Plastic Surgeon
5.0 out of 5 stars 15 reviews

DIEP flap

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.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

DIEP Flap Recommendations

There are several important criteria to consider in choosing a breast reconstruction surgeon to perform your DIEP flap surgery.  

In addition to general plastic surgery training, your surgeon needs extensive experience in microvascular surgery.    It is important that your surgeon be experienced in these techniques and perform them with minimal rates of complication or flap failure.

Most major medical centers have breast cancer centers and support groups.   They are an excellent resource to inquire about the best breast reconstruction surgeons in your area.    In addition, your breast cancer surgeon should be able to provide you with a consultation by an experienced microvascular surgeon.

Bottom line, ask the people who know, your healthcare providers and hospital support groups.   All the best in your reconstructive journey

Paul S. Gill, M.D.

Gill Plastic Surgery

Houston Double Board Certified Plastic Surgeon

Paul S. Gill, MD
Houston Plastic Surgeon
4.8 out of 5 stars 85 reviews

DIEP Flap Recommendations

Regarding: " Recommendations for the best reconstructive surgeons who do DIEP   Also Is it true that doctors do not know in advance if they can do a DIEP reconstruction until they get inside?"

The DIEP flap is the latest in microsurgical reconstruction flaps used mostly for the breast. Surgeons DO and plan in advance on how to do it, allocating team members to do certain parts of the surgery simultaneously and getting the equipment needed to visualize where the perforating blood vessels are located.  One of the busiest groups in the country dedicated to DIEP flaps is run by Bob Allen of Charleston who has more experience with this surgery than anyone else. Dr. Allen operates in Both New York and Charleston. You can easily find him on line.

Peter A. Aldea, MD
Memphis Plastic Surgeon
4.9 out of 5 stars 109 reviews

Selecting a DIEP Flap surgeon

I recommend you meet with a ASPS member surgeon who regularly performs this procedure on a weekly basis.  As with anything in medicine/surgery, experience matters.  A DIEP free flap is a muscle sparing tissue-only reconstructive modality.  It is essentially a tissue transplantation procedure.  In every major city, there is usually at least one or two groups who perform DIEP flap procedures on a weekly basis.  The good news is that the DIEP free flap should be covered by your insurance as this is a reconstructive procedure for breast cancer/mastectomy reconstruction.  

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.7 out of 5 stars 212 reviews

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.