Abdominally-based autologous breast reconstruction is an advanced microsurgical technique for patients interested in more natural breast reconstruction after mastectomy with their own tissues. This technique transfers tissue from your abdomen to create a new breast mound, preserving the natural look and feel of your breasts, while avoiding the use of implants. The flap of tissue from your abdomen is named the deep-inferior epigastric perforator (DIEP) flap from the artery and vein that supply the tissue. By carefully harvesting and reshaping the abdominal skin and fat, Dr. Chang reconstructs a breast that mirrors your original contour, ensuring both aesthetic appeal and a seamless integration with your body. This approach not only enhances your post-mastectomy appearance but also offers the benefit of a flatter abdomen, providing a beautiful and harmonious result.

Overview & Why Choose Dr. Chang

Autologous Reconstruction with Abdominal Free Flap 

  • Patients Undergoing Mastectomy – The DIEP flap is a good option for the majority of patients undergoing mastectomy. Patients can choose, to an extent, if they would like to remain roughly the same size, smaller than, or larger than their pre-operative breast size. The size of the reconstructed breasts is limited by the amount of skin and fat you have in the lower half of your abdomen.

  • Patients with the Optimal Abdominal Skin and Fat Excess and Who Are Interested in Aesthetic Contouring of the Abdomen – In order to be a good candidate for a DIEP flap, you must have sufficient excess skin and fat of your lower abdomen (below the umbilicus) to reconstruct a breast of your desired size. Very thin patients may not have enough tissue to create an aesthetic breast mound and are better candidates for implant-based breast reconstruction. On the other side, if you have too much excess skin and fat, particularly patients with BMI > 35 with a lot of intra-abdominal fat, then you are not a good candidate because of the increased risk of complications.

  • Patients with Minimal Prior Abdominal Surgery – Patients with prior abdominal surgeries have to be evaluated carefully before considering reconstruction with a DIEP flap. Any abdominal surgery causes scarring and carries the risk of injuring the blood vessels to the abdominal skin and fat. Open surgeries pose a significantly greater risk than laparoscopic or robotic surgeries or C-sections. Patients with ventral hernias are not candidates for this surgery. 

  • Patients Who Need Radiation Therapy – Patients who need or have had radiation therapy are best treated with staged autologous breast reconstruction. In the first stage, a tissue expander is used to maintain some of the breast pocket during the radiation period. Because radiation induces so much scarring, DIEP flap reconstruction is an excellent option because most of the radiation-damaged tissues are replaced with completely healthy abdominal tissue.

  • Patients Who Have Failed Implant-Based Breast Reconstruction – Patients who have failed implant-based breast reconstruction for any reason may benefit from reconstruction with a DIEP flap.

  • Healthy Patients – Healthy, non-smoking patients without major medical conditions that would make surgery or general anesthesia unsafe are candidates for this surgery. Conditions that pre-dispose to increased complications such as diabetes, vascular disease, autoimmune conditions, immunodeficiencies, etc. are still candidates for surgery but require additional pre-operative counseling and optimization. Certain conditions—namely blood clots, hypercoagulable disorders, and bleeding disorders—will require more thorough discussion with Dr. Chang and your primary care provider to determine if proceeding with DIEP reconstruction is safe for you.

  • Realistic Expectations – Dr. Chang views surgery as a partnership between the patient and him. It is important trust and confidence go both ways. Together, we will discuss your goals and if we can reasonably achieve those goals based on your anatomy.


Who Is a Candidate for DIEP Flap Reconstruction?

  • Medical Evaluation – Dr. Chang will review your medical conditions, medications, prior surgeries, and personal and family history of breast diseases, masses, and cancers. Some patients may be referred to their primary care doctor or a specialist to ensure you are medically optimized for a safe surgery under general anesthesia and post-operative recovery. 

  • Breast Examination – Dr. Chang will perform a physical examination of your breasts. This will include measurements of the size, location, and symmetry of the breasts and nipple-areolar complexes. Dr. Chang will assess the skin quality, the weight/volume of excess breast tissue relative to your desired size, and the positions of the nipple areolar complexes to help determine the best surgical approach.

  • Abdominal Examination – Dr. Chang will perform a physical examination of your abdomen. This will include assessing the skin quality and excess, location and type of fat excess, and muscle quality. Dr. Chang will examine for prior scars and evaluate for the presence of hernias.

  • Clinical Photographs – Clinical photographs from multiple views will be taken of your breasts and abdomen. These photos are used to plan for your individualized surgery and compare before and after surgery. No photographs will be published online without your written consent.

  • Imaging Studies – CT angiogram studies are obtained pre-operatively. This study uses a contrast dye to evaluate the number, location, and quality of the blood vessels that may be selected in your DIEP flap. This study facilitates surgical planning and expedites intra-operative decision making.



Pre-Operative

After completion of the microsurgery portion, the flap is inset into the breast pocket and shaped to form a breast mound. It is important to know that the goal of the initial DIEP flap is just to transfer a living flap up to the chest. Your breasts likely will not look as you desire after this first surgery. Almost all patients undergo a revision surgery to improve the aesthetic size, position, and contour of the breasts.

Flap Inset

Now that the DIEP flap is harvested on its source artery and vein and the recipient chest artery and vein are prepared, the arteries and veins are micro surgically repaired to each other. This step requires the use of an operating microscope and is critical that it is performed correctly. If the artery or vein repair fail, then the entire reconstruction fails. It is for this reason that you are monitored very closely in the hospital in case we need to return to the operating room to fix one of the vascular repairs.

Microsurgery

The incisions for the DIEP flap are similar to, but not the same as, those for an abdominoplasty. They are similar in that the final scar is a transverse line from hip to hip. In an abdominoplasty, the incision is made as low as possible to be well-hidden in your underwear line. While the goal is to also hide the DIEP incision in your underwear line, sometimes the final scar is a little bit higher than that of an abdominoplasty in order to make sure the blood vessels supply the DIEP flap are included. The DIEP flap harvest involves identifying, selecting, and dissecting one to several of the perforating blood vessels that supplies the skin and fat of the lower part of your abdomen (below your umbilicus). In order to have an artery and vein that match the size of the recipient vessels in the chest, the fascia surrounding your rectus abdominis muscles is opened so that the source vessels, the deep inferior epigastric artery and vein can be accessed. In some cases, the blood vessels are dissected completely away from the rectus abdominis muscle. This is called a DIEP flap. In other cases, a small amount of muscle is included to protect the blood vessels. This is called a muscle-sparing transverse rectus abdominis (msTRAM) flap. After the flap is isolated from the source vessels, it is completely separated from the abdomen to be used in the breast. The muscle and fascia incision are repaired and reinforced with an absorbable mesh to reduce the risk of bulging. The abdominal incisions are closed, and the umbilicus is brought out through a new location. Unlike an abdominoplasty, liposuction is never performed at the time of the DIEP flap, and muscle plication (rectus diastasis repair) is only performed in select cases.


Abdominal Flap Harvest 

Following the mastectomy or removal of tissue expander or implants, the breast pocket is adjusted to accommodate the size of the desired flap. Because the DIEP flap is a large piece of tissue, simply suturing it into the breast pocket will not work. The tissue would die without a blood supply. In the chest, the recipient artery and vein, which will be used to supply the flap are prepared. In the vast majority of cases, the internal mammary vessels are used and involves removing a small segment of one of your ribs. Because of the redundancy in blood supply to your body, rerouting the internal mammary vessels to supply the DIEP flap does not have any clinically relevant negative consequences. In the case that the internal mammary vessels are not used, blood vessels in your axilla may be used instead. In very rare cases, a vein from your arm may be used. This portion of the procedure is performed through your previous mastectomy incision, which may be extended as needed to facilitate the safety of the surgery.


Breast Pocket and Recipient Vessel Preparation 

Breast reconstruction with DIEP flaps, similar to implant-based breast reconstruction, can be performed immediately at the time of mastectomy or delayed, following tissue expander placement at time of mastectomy. Multiple factors are at play when determining whether to perform the DIEP reconstruction immediately or delayed, and you and Dr. Chang will make that decision on a case-to-case basis. Because of the complexity of this surgery, a co-surgeon approach is taken, where Dr. Chang and another well-trained plastic surgeon work together to help give you the best result safely. The goal of the initial DIEP reconstruction is to establish a well-vascularized breast mound framework from tissue from your abdomen. From this framework, the reconstructed breast can be more aesthetically contoured in a second stage. Almost all patients undergo a revision surgery after the initial DIEP flap to help adjust for desired breast volume, aesthetic contour, symmetry, and to better perfect the abdominal contour.

Overview

How Is DIEP/msTRAM Performed?

If you have any urgent concerns, you may call the office at any time. Otherwise, patients should expect follow-up visits at 1 week, 2 weeks, 1 month, and 3 months. At your 3 month appointment, we will discuss your planned revision surgery, generally between 6-12 months after your flap reconstruction.

Follow-Up Visits

Immediately after surgery, you will be admitted to the hospital for pain control, fluid control, and close monitoring of your flap. For many hospitals, this means an admission to the ICU to ensure you have the appropriate nursing care. You will not be allowed to eat or drink anything until Dr. Chang evaluates you the morning after surgery. If a problem with your flap were to occur, it most likely manifests within the first 12-24 hours. That would warrant an urgent trip back to the OR to try to salvage your flap reconstruction. Problems with the flap may arise beyond the 24 hour mark, but unfortunately those are associated with lower rates of salvage success. After the OR, your nurse will be examining your surgical sites hourly and will report to Dr. Chang if there are any concerns about the flap. The day after surgery, once cleared by Dr. Chang, you will be allowed to eat, get out of bed to a chair, have your urinary catheter removed, and then start to ambulate. Once your pain is well controlled and you are able to stay hydrated and ambulate on your own, you may go home. For most patients, that is on post-op day 2 or 3. Depending on your occupation, you may return to work 2-4 weeks after surgery. You may resume light cardio exercises at 4 weeks after surgery. You should not lift anything heavier than 5 pounds or extend your arms extensively over your head for the first 4 weeks after surgery. You may resume all physical activities at 6-8 weeks after surgery. You should expect some drainage from the incisions and mild bruising around the incisions. You will be swollen, and it can take up to 3-6 months for the swelling to reside. Your incisions will take 2-4 weeks to completely heal, but the final scar will take 6-12 months to mature. Scar care will be discussed at your 1 month post-operative appointment.

Recovery Period

Local anesthetic (numbing medication) will be injected at your surgical sites to minimize your immediate post-operative pain. You should take acetaminophen and an NSAID around-the-clock, according to instruction, for the first 72 hours and then as-needed thereafter. You can purchase these over-the-counter. You will be given a small number of low-dose narcotic pain medications for breakthrough pain only for the first 72 hours.

Pain Management and Medications 

Your incisions will be dressed with surgical bandage strips and/or surgical skin glue. You will be wearing a comfortable surgical bra stuffed with gauze pads. The bra should be relatively loose. You should try to wear the surgical bra as much as possible but may remove to shower and to wash the bra. You may shower the day after surgery but cannot bathe or swim until instructed to do so. You will have a compressive abdominal binder on. You will have drains in your breasts and abdomen.

Dressings and Incision Care 

Post - Operative

  • Immediate Flap Failure – Your reconstructed breast made from the skin and fat of the DIEP flap is dependent on the newly established blood supply. If a blood clot were to form in the artery or vein or either becomes kinked or compressed, the blood supply to the flap decreases and the flap may die. Despite meticulous suturing of the vessels under the microscope, 1-5% of flaps will unfortunately fail. Immediate flap failure occurs within the first 72 hours of surgery during your hospital stay. Every attempt will be made to fix the problem in the OR. The further out from surgery you are, the less likely a problem occurs, but if a problem occurs, the chances of successfully fixing it decreases. If the flap fails, it will be removed and replaced with a tissue expander, and a different form of breast reconstruction will be performed at a later date.

  • Delayed Flap Failure – Delayed flap failure occurs beyond the first 72 hours that you are in the hospital. Unfortunately, salvage rates of these failures are very low. If this happens, you will be instructed to come into the hospital to have the flap removed and converted to a tissue expander for a different type of delayed reconstruction performed at a later date.

  • Partial Flap Loss – Partial flap loss occurs when some of the flap survives but some of the flap does not. The part of the flap that does not survive typically forms hardened scar tissue, called fat necrosis. While not harmful, this scar tissue can be discomforting and is generally excised during your revision surgery.

  • Abdominal Bulge – An abdominal bulge occurs when the muscle and fascia of your abdominal wall are weakened. When it is weakened, the organs inside your abdomen bulge outward through the weakened portion of the abdominal wall. While not a true hernia as there is not a hole in your abdominal wall, bulges can be functionally problematic and aesthetically displeasing. The risk of bulging is higher in patients with risk factors for poor wound healing and especially in higher BMI patients. The risk of bulging is one of the reasons Dr. Chang has a BMI cutoff for performing DIEP flaps. Although Dr. Chang tries to minimize the risk of bulges through careful dissection, muscle preservation, and mesh reinforcement, bulges may still occur. If significantly bothersome, they will require a revision surgery.

  • DVT/PE – Because of the length of surgery, your decreased mobility afterwards, and the fact that your abdominal wall is tightened during surgery, you are at increased risk of major blood clots forming. While most start in the legs, they can travel to your lungs, making it difficult for you to breathe and be potentially life threatening. All patients are given intermittent compression stockings during the surgery and post-op and are on prophylactic blood thinning medications to reduce the risk of blood clots. Patients with a personal or family history of blood clots may be recommended against DIEP flap reconstruction.

  • Pneumothorax – In order to prepare the recipient blood vessels, a section of rib will be removed. During this process, one of the tissue layers that protects your lungs may be injured, which could cause air to build up around, instead of inside your lungs, which makes it difficult to breathe and potentially life threatening. In these cases, the injured tissue layer will be repaired, and a chest tube will be placed to help remove any air that accumulates during the healing process.

  • Bleeding – Significant bleeding after surgery may require an urgent return to the operating room. Smaller collections of blood may be treated conservatively or managed with a small procedure in the office or the operative room.

  • Need for Blood Transfusion – Because DIEP flap reconstruction is a major surgery, blood loss is expected. Sometimes, patients will need a blood transfusion.

  • Asymmetry – No one’s breasts are perfectly symmetric. While the goal is near-perfect symmetry, there will be some asymmetries in your reconstructed breasts.

  • Need for Revision Surgery – All patients undergoing DIEP flap reconstruction will be recommended for at least one revision surgery. The revision surgery helps achieve your desired breast size, position, contour, and symmetry. Sometimes, multiple, staged revision surgeries are needed.

  • Unmet Expectations – Despite thorough pre-operative planning and discussions, you still may not be fully happy with your aesthetic results.

  • Poor Scarring – Everyone scars differently. The final scar takes 6-12 months to mature. In rare cases, hypertrophic scars or keloids may form and may require secondary revision.

  • Wound Healing Issues – There may be small areas where the incisions do not fully heal. In these cases, the wounds will be allowed to heal on their own with dressing changes. Severe cases may require a secondary revision procedure.

  • Infection – Infections are managed with antibiotics. In severe cases, you may need an additional procedure.

  • Seroma – Fluid collections may develop in the chest. Small ones will be absorbed by the body, but larger ones will need to be aspirated in the clinic.



Risks of DIEP Reconstruction

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