DIEP flap surgery: Get natural breasts again after mastectomy — without implants

October 03, 2018 | by Lucio Pavone, M.D.

Women who want breast reconstruction after mastectomy now have an advanced option that looks and feels natural, lasts longer than implants and even offers a mini tummy tuck as part of the procedure.

Deep inferior epigastric perforator artery surgery, or DIEP flap (pronounced deep flap), creates a new breast with fat and skin from a woman’s abdomen. The result? Natural breasts that can regain sensitivity over time and potentially reduce the risk or severity of painful lymphedema in the arms.

Patients in the Chicagoland area have a distinct advantage at Edward-Elmhurst Health: both Iris Seitz, M.D., and myself are board-certified microsurgeons. We are experts in operating on the tiny nerves and blood vessels of the abdomen, breasts and lymphatic system.

Edward-Elmhurst Health is a high-volume center for DIEP flap procedures, which means we perform a lot of flap procedures and provide ongoing care for many women who’ve had them in the past.

But what’s really unique about our program is that Dr. Seitz and I perform all of our patients’ DIEP flap procedures as a team. In fact, we joined the health system together specifically to perform this procedure. Patients benefit from our double-surgeon approach through:

  • Combined expertise
  • Continuous monitoring during recovery
  • Excellent outcomes
  • Shorter procedures

Who is a good candidate for DIEP flap surgery?

Nearly every woman who’s eligible for breast cancer reconstruction is a candidate for DIEP flap surgery. We perform this procedure on women as young as 40 and into their 70s, with the average patient being in her 50s.

Before a patient chooses DIEP flap, we review her health history and conduct a physical exam, including a CT scan to check for any concerns with the blood vessels in her abdominal tissue. Then we talk through:

  • Before and after photos
  • Benefits and risks
  • Cancer treatment needs, such as radiation
  • Surgery preparation and recovery

We also discuss insurance coverage. A federal mandate states that DIEP flap and other breast reconstruction procedures related to breast cancer must be covered by insurance. However, insurance does not cover DIEP flap if it’s done for purely cosmetic reasons.

Approximately 60 percent of our DIEP flap patients have had both breasts removed (bilateral mastectomy) to reduce the risk of breast cancer coming back or as a preventive measure due to genetic risk for breast cancer. Women who have both breasts removed and reconstructed at the same time can avoid having lopsided breasts or needing additional reconstruction surgeries down the road.

The beauty of the DIEP flap procedure is that we can perform it at the same time as the mastectomy. That said, we often do the surgery after a woman’s radiation therapy ends — we’ve even done DIEP flap for women who ended cancer treatment 20 years ago!

But it’s important to note that DIEP flap is a one-and-done procedure. Once we remove a portion of the patient’s tummy fat and skin for transfer, we can’t safely do it again. Her only option for future reconstruction, if desired, would be implants.

Interested in DIEP flap surgery? Call us today at 630-646-6020 or schedule a consultation online.

How does the DIEP flap procedure work?

Together, Dr. Seitz and I typically can complete a DIEP flap procedure for two breasts in 8-10 hours. If we attempted it solo or if we were paired with less-skilled surgeons, the process would take much longer and would be riskier for patients.

First, we use a sophisticated microscope to carefully dissect the blood vessels and nerves of the abdominal tissue — most of which are smaller than 2 mm in diameter. Next, we remove a section of healthy skin, fat and lymph nodes from the patient’s abdomen, essentially giving her a tummy tuck.

After we have removed the tumor and any necessary tissue, we transfer the abdominal tissue to the chest and carefully connect its blood vessels to the breast tissue. We also replace the damaged breast nerves with healthy nerves in an advanced process called neurotization. Neurotization is thought to improve sensation in the breasts over time. 

Next, we perform any lymphedema surgery the patient might need. Finally, we close her incisions and take her to the intensive care unit (ICU) for recovery and observation.

Most patients stay in the hospital 3-4 days after surgery for observation and pain management. Patients stay in the ICU during this time because it’s close to the plastic surgery unit, which allows our nurses to check the patient’s flap perfusion (the flow of blood flow through the new breast) more frequently.

Before we send a patient home from the hospital, we provide her with information about self-care at home. Patients typically come back for a follow-up visit a week after surgery, then two weeks, and then 4-6 weeks, depending on their healing progress. After that, we like to see patients once a year to monitor their health.

Most patients can expect a full recovery within six weeks, but they should avoid strenuous activity, such as endurance exercise or heavy lifting, for three months.

What lymphedema treatment is available?

Dr. Seitz and I regularly perform two advanced procedures to control lymphedema in combination with DIEP flap surgery:

  • Vascularized lymph node transfer: In this procedure, we take healthy lymph nodes from the flap tissue and transplant them into the chest and armpit area to rebuild as much of the lymphatic system as possible. Edward-Elmhurst Health is among just a handful of comprehensive cancer centers that offer this procedure, which is considered supermicrosurgery. The blood vessels involved are smaller than 1 mm in diameter.
  • Lymphaticovenular bypass:In this procedure, we reroute lymphatic fluid that normally would drain through lymph nodes in the armpit area to drain through lymph nodes in other parts of the body. We map out these tiny channels using SPY ICG technology, which is a dye process that shows us the lymphatic system under an infrared camera before we even make an incision.

What are the risks involved with DIEP flap surgery?

Complications with DIEP flap procedures are rare, but when they occur, it’s typically within 48 hours of surgery. Tiny blood clots or twists in the delicate blood vessels can cause the flap to fail, which means the tissue turns purplish-blue and dies. In the rare event this happens, quick intervention by our nursing staff and a helpful DIEP flap app can help us act quickly to save the new breast with additional surgery. Between the expertise of Dr. Seitz and myself, our flap failure rate is close to zero.

DIEP flap surgery? There’s an app for that!

All DIEP flap patients are monitored 24/7 with ViOptix, a smartphone app that allows the care team to watch for signs that a patient’s flap might be failing. Though flap failure is rare, the greatest risk is within the first 48 hours after surgery.

During each patient’s hospital stay, she’ll wear a tiny sticky pad on her new breasts. The pad connects to a special machine that evaluates and sends blood flow information to the ViOptix app, which shows Dr. Seitz and me in real-time the patient’s perfusion levels on a graph. Dips in the numbers set off a smartphone alert, which indicates that we need to get to the hospital, assess our patient and potentially perform additional surgery to save the flap.

What outcomes can a woman expect?

Here in the Chicago area, most women see a plastic surgeon to understand their reconstruction options before they have a mastectomy. Unfortunately, this isn’t true everywhere.

Some doctors aren’t up-to-date on current techniques and don’t offer a plastic surgery consultation. Also, some patients feel overwhelmed by their diagnoses and have difficulty fully understanding their options. When these patients come to us, many are frustrated, and rightly so.

For example, we treated a patient whose breast cancer journey had been a nightmare. She’d had a bilateral mastectomy at another center but either wasn’t told or didn’t understand that she would need radiation after surgery. She received implants during her breast cancer surgery, which caused complications during treatment and had to be removed.

The patient felt like her former doctor didn’t care about her situation, so she came to see Dr. Seitz and me. We talked through her concerns and suggested DIEP flap surgery, which we thoroughly explained. We answered all her questions, and the natural approach appealed to her.

Within moments of waking from surgery, the patient was like a completely different person. She asked for her smartphone and immediately jumped on a DIEP flap support group page, where she began to rave about her wonderful experience with our team. More importantly, it was the first time we’d ever seen her smile!

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