March 25, 2022
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By Dr. Andrew Campbell-Lloyd

DIEP flap breast reconstruction

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Information

COSTS:
Plastic surgeon’s out-of-pocket fee: from $500 +post-operative care costs (from $2000) + surgical garments (approx. $400)

Co-surgeon’s out-of-pocket fee: from $500

Please note that the out-of-pockets fees may vary significantly depending on your health fund.

Surgical Assistant's fee: $500-$1000

Associated item numbers: 45564, 45565, 45504, 45505, 45569, 45570 + others

Level of health insurance cover recommended: Silver tier (bronze policies may be sufficient for index procedure depending on your fund, but we generally recommend higher cover)

LENGTH OF PROCEDURE/HOSPITAL STAY:
5-8 hours - 2 surgeons, with assistants

4-5 night stay in hospital

What is a DIEP flap?

A “free flap” is a term used by plastic surgeons to refer to a piece of tissue (in this case, fat and skin from the lower abdomen) with the blood vessels that nourish it. A free flap can be moved from one part of thebody to another using microsurgery. Dr Campbell-Lloyd is an experienced microsurgeon who has performed many hundreds of these procedures.

The DIEP flap is the gold-standard in breast reconstruction.The lower abdominal skin and fat tissue can be harvested, transferred to the chest and moulded into a breast shape. This tissue is totally natural, warm and soft. The DIEP flap feels and moves in a way that is almost identical to a natural breast. Once the microsurgery has been performed, the DIEP flap has a new blood supply which makes it a living part of the body.

The DIEP flap can be performed at the time of mastectomy, or at any time after a mastectomy has been performed. The timing of the surgery will alter the scar pattern and the appearance of the reconstructed breast.

Key Features

Muscle preservation:

A key feature of the DIEP flap (and the major benefit over the old fashioned "TRAM flap" which involves the same, lower abdominal donor site) is the total preservation of the Rectus abdominus (the “six-pack”) muscle. Provided the surgery is performed by an experienced surgeon, not only is the muscle spared, but the nerves which allow that muscle to contract are also preserved, ensuring that the muscle functions normally after surgery.

Preservation of the muscle may have some benefits in the recovery from surgery. There may be less pain, there is a decreased risk of hernia or bulge, and in my opinion, muscle-sparing surgery also lowers the perceived barriers to surgery.

Interestingly, many ladies will express their relief at the idea of the muscle being preserved. Once this aspect of the DIEP flap is explained, there are ladies who feel far more comfortable with the idea of autologous reconstruction. Some ladies would otherwise reject autologous reconstruction if they were offered a TRAM flap.

 

Immediate or delayed

The DIEP flap offers enormous flexibility.

Immediate breast reconstruction, at the time of the mastectomy,allows for preservation of the breast skin (and possibly the nipple). The tissue removed in the mastectomy can then be replaced by the abdominal fat which is buried under the breast skin. The abdominal fat can be shaped to match the removed breast, and this offers the best chance to create a symmetrical result when only one breast is removed.

Delayed breast reconstruction is performed months or years after a previous “simple” mastectomy. Most women in these cases have lived with a flat chest (on one side or both), and the associated long, tight scars. The important thing to understand about delayed reconstruction is that the DIEP flap is the best (indeed, the only) way to replace what has been taken away. Ladies who have a simple mastectomy have the breast tissue and the skin of the breast removed. Therefore, a successful breast reconstruction requires the replacement of both the volume of the breast tissue, as well as the skin of the breast. The abdominal tissue can be harvested to include both a substantial amount of fat tissue (to replace the breast) and skin (to replace the excised breast skin). Delayed breast reconstruction has a very different pattern of scars, and a different appearance as a consequence, when compared to immediate reconstruction.

 

Unilateral or bilateral

In most cases, whilst the use of the lower abdominal tissue to make a breast will lead to a “tummy-tuck” style scar, we only use about half of that tissue to reconstruct one breast. Which of course means that we can rebuild one or two breasts using the entirety of that tissue.

Slim ladies with a larger bust can use both sides of the abdomen to rebuild just one breast, using a technique sometimes referred to as “stacking”. In stacked flap procedures, two flaps are connected microsurgically to one side of the chest to rebuild a larger breast.

There is an unfortunate trend recently towards double mastectomies. Many women with breast cancer, even those with small, good prognosis tumours, are being guided towards or choosing to have double mastectomies. This is very frequently based on a misinterpretation or misunderstanding of the risk of developing breast cancer in the opposite breast.

The increasing rate of double mastectomy is important to consider because it may have unintended consequences for patients when they seek reconstruction.

The lower abdomen is a sufficient donor site in most women to create two breasts. However, some women - typically those who are slender with a larger bust - will not have sufficient tissue to make two reconstructed breasts that are the same size as their natural breasts. It is vital that women understand this, as it can significantly affect body image after surgery if the reconstructed breast is smaller than the natural breast.

 

Your own tissue: warm, soft, natural movement

The DIEP flap allows us to create a totally natural reconstructed breast. The tissue is warm, soft and has a natural bounce, so in every way it looks and moves like a natural breast.

Over time, the DIEP flap will behave just like a normal breast. The reconstructed breast will fluctuate in size with body weight, and will age naturally over time.

These are features that can never be replicated with an implant reconstruction.

Unfortunately, the DIEP flap will not have normal sensation after reconstruction. Whilst techniques are in development to allow sensory recovery, these are not yet considered reliable or in common use. In some circumstances, nerves in the abdominal tissue can be connected to nerves in the breast, however this is unreliable. Even with these techniques, the breast skin will typically remain numb, and the recovery of sensation in the breast skin is dependent on the matectomy performed by your breast surgeon.

The only option for symmetrical unilateral reconstruction

For many ladies, a major motivation to have a double mastectomy is the fact that it is impossible to reconstruct one breast with a breast implant and have it match a natural breast. Because many ladies are never offered the opportunity to consult with a Plastic Surgeon prior to their mastectomy, when they are told that it is better to have double mastectomy with implant reconstruction, they assume this is the best option.

The DIEP flap is the only way to reconstruct one breast and create symmetry with a natural breast on the other side. Whether performed at the time of mastectomy, or down the track, the DIEP flap can simulate and match a natural breastin shape, size, and movement.

Dr Campbell-Lloyd strongly advocates against unnecessary double mastectomy operations. These procedures double the risk, may offer little to no benefit, and can substantially complicate the reconstructive process. It is vital that patients feel comfortable to have a frank discussion with their breast surgeon about pros and cons of double mastectomy.

Redundant/excess abdominal tissue removed

For many ladies, the use of the abdominal tissue for breast reconstruction, and the "tummy-tuck" style closure of the abdomen, offers a secondary benefit to the breast reconstruction process.

It is important that patients considering DIEP flap breast reconstruction are healthy, and at an appropriate weight. Patients whose BMI is greater than 30 may not be candidates for DIEP flap surgery (this is the same criteria that Dr Campbell-Lloyd applies to patients considering a tummy-tuck) due to the increased risk of wound healing problems.

Allows for nipple reconstruction with tattoo

There are a range of different mastectomy operations that may be performed. These variations may be guided by the type of breast cancer, the location of the tumour, the age of the patient and the shape/size of the breast. It is not possible to save the nipple in all cases, and where the nipple must be removed with the mastectomy, an added benefit of the DIEP flap is that it supports a nipple reconstruction being performed several months after the mastectomy.

Once a nipple has been reconstructed, a medical tattooist can then recreate the colouring of the nipple and areola with a "3D tattoo".

Associated procedures:

  • Breast implant removal and capsulectomy (when the DIEP flap is performed for revision of a previous implant-based reconstruction).
  • Skin reduction ("Wise-pattern mastectomy") to decrease the size of the reconstructed bust in very large breasted women - this is a complex procedure which does create increased risk of wound healing problems.

Reasons To Consider This Procedure

Mastectomy for breast cancer treatment:

No matter the type of mastectomy operation you require, or have already had, the DIEP flap is the most flexible and robust form of breast reconstruction, and the only option for creating a natural breast.

Previous implant-based breast reconstruction:

Dr Campbell-Lloyd has developed a number of techniques for revising and improving previous implant-based reconstructions performed elsewhere. However, replacing breast implants with a DIEP flap remains the ultimate form of revision.

This has become a common procedure for Dr Campbell-Lloyd. Many women present with complications associated with breast implants when used for reconstruction. Thes complications include pain, contracture, implant animation, poor shape, tightness, and a general dissatisfaction with the feel and aesthetic result from previous surgery.

An example of a previous implant-based breast reconstruction which has been revised with removal of implants and replacement with DIEP flaps.

Implant replacement with DIEP flaps is an excellent solution for many women. We also increasingly use a similar technique called "delayed-immediate" reconstruction for ladies who require urgent mastectomy but may be unsure how they wish to proceed with reconstruction, or for ladies in whom there is a concern about wound healing. The delayed-immedaite breast reconstruction involves the placement of a breast implant or tissue expander at the time of mastectomy (the immediate reconstruction), with the intention to replace that implant within a short time-frame (usually 3-6 months) with a DIEP flap (the "delayed" part of the reconstruction. This approach has a number of unique benefits.

Previous radiotherapy:

Ladies who have had a simple mastectomy followed by radiotherapy often present to Dr Campbell-Lloyd with the issue of significant tightness in the chest skin, compounding the fact that they have been left "flat" after this type of mastectomy.

Radiotherapy can be a very damaging form of treatment, which whilst necessary, creates specific considerations when performing reconstruction. The radiotherapy induces a scar-like response in the affected tissues (we call this response "fibrosis"). The tissues affected include the skin and the Pectoralis major muscle.

Generally speaking, Dr Campbell-Lloyd will not offer implant-based reconstruction to ladies who have had radiotherapy. The DIEP flap is the ideal reconstruction in these circumstances as it allows us to introduce healthy tissue (from the abdomen) which is unaffected by radiotherapy, onto the chest. This allows for the release and relief of the tightness so many women will experience, whilst also creating the ideal breast shape.

Preference to avoid the use of silicone breast implants:

An increasing number of women are choosing to avoid the use of silicone breast implants. For these ladies, the ability to reconstruct the breast using their own tissues is a valued option.

The DIEP flap is a totally natural form of breast reconstruction.

What To Expect

Very high rate of success compared to implant reconstruction

The DIEP flap is a very reliable, safe procedure. We advise patients that there is a 1 in 200 chance of the flap surgery not being successful. However, the risk of implant-based reconstruction failing (due to infection, fluid collections, wound healing issues etc.) is much higher; there is approximately a 1 in 10 chance that breast implant reconstruction will fail at some stage, and every breast implant reconstruction will require additional procedures, often on multiple occasions. A successful DIEP flap will create a permanent, life-long result with no need for additional surgery in many cases.

Recovery:

4-5 nights in hospital

Physical limitations for 6 weeks

3-4 months of recovery

Abdominal tightness which can persist for 6-12 months

Garments must be worn for 6 weeks

Revision procedures, including nipple reconstruction, can be performed from 3 months

All sutures are dissolving sutures, under the skin. A layer of glue is then applied to any incisions. There are no “sticky” dressings which could cause irritation and prevent showering.

After DIEP flap surgery, patients are discharged home with a surgical compression bra which must be worn at all times for the first 4-6 weeks.

Patients are discharged with antibiotic tablets, and pain-relief medications.

Patients are discharged home with detailed instructions. The instructions include emergency contact details for Campbell-Lloyd.

Routine follow-up appointments are made for (although patients may be seen more frequently):

  • 1 week post-discharge,
  • 4-6 weeks post-op,
  • and 3-4 months post-op

There will be some pain. Most patients will experience pain at the incision sites for the first 7-10 days. Most patients will have discomfort in the abdomen, but very frequently will not have significant discomfort in the breast. Some patients will experience occasional discomforts relating to movement after that time as the healing process continues.

The nature of this surgery is such that patients should expect to require pain relief medication for at least the first 2-3 weeks. Some patients will require simple pain relief (such as Nurofen) for up to 6 weeks as they increase activity.

It is vital to maintain a decreased level of activity for 6 weeks after surgery.

It will take at least 3-4 months for full recovery. Some ladies will describe a persisting feeling of fatigue during this time. This is quite normal.

We normally recommend that ladies having mastectomy with immediate DIEP flap reconstruction should expect to require 3-4 months OFF WORK.

Final results can only be appreciated after that time, once scars have softened and relaxed. Scars may only fade after 6-12 months on the breast.

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