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| DIEP flap | |
|---|---|
| Specialty | Plastic surgery |
A DIEP flap is type of breast reconstruction where blood vessels, fat, and skin from the lower belly are relocated to the chest to rebuild breasts after mastectomy. [1] DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. This is a type of autologous reconstruction, meaning one's own tissue is used.
The DIEP flap reconstruction procedure is similar to the muscle-sparing free TRAM flap procedure, but it only requires the removal of skin and fat. Unlike in the TRAM procedure, however, no muscle is sacrificed. [1] The DIEP flap—like the TRAM flap—requires an incision into the abdominal (rectus) muscle, as the blood vessels, or perforators, required to keep the tissue alive lie just beneath or within this muscle. Therefore, a small incision is made in the abdominal muscle in order to access the vessels.
After the skin, tissues and perforators (collectively known as the "flap") have been dissected, the flap is transplanted and connected to the patient's chest using microsurgery. The plastic surgeon then shapes the flap to create the new breast. As no abdominal muscle is removed or transferred to the breast, patients typically see a lower risk of losing abdominal muscle strength and may experience a faster recovery compared to TRAM flap patients. [1] Studies comparing abdominal results with the muscle-sparing free TRAM and the DIEP show that abdominal wall hernias occur less frequently in DIEP patients, although the abdominal wall bulge rates are similar for both procedures. [2]
Many women who undergo this form of reconstruction enjoy the added benefit of a flatter abdomen with results that mimic a “tummy tuck” procedure. However, one risk of these procedures is the potential denervation of the abdominal musculature following the DIEP dissection. The initial DIEP flap reconstruction takes an average of six to eight hours, however surgeries lasting 16 hours or even longer are not unheard of. [3]
DIEP flap breast reconstruction is typically performed by the Plastic Surgery team (rather than the Breast Surgery team) so is only available in centres with Plastic Surgery support. It is a more complicated operation than other autologous or alloplastic options, but provides significantly better cosmetic results, which means better psychological outcomes and with a lower risk of reconstruction failure. [4] Recent advances in preoperative imaging of the blood vessels in the abdomen (using CT or MRI scans), operative time and complication rates can be reduced in DIEP flap breast reconstruction. [4]
DIEP flap surgery is a type of breast reconstruction after a mastectomy of a single or both breasts by using abdominal fat, skin, and blood vessels from the patient's own body.
Natural fat tissue is harvested from the belly and used to replace the breast tissue removed during mastectomy. The breast will also gain weight and lose weight in line with the rest of the body so that both breasts will retain symmetry of size. Usually there is no long term follow-up surgery required in the future as may be the case with silicone implants, however patients may require a longer hospital stay at the time of the operation to monitor the flap in the immediate post-operative phase where those receiving implants can sometimes be done as a day case.[ citation needed ]
The operation can be performed at the time of the mastectomy (immediate breast reconstruction) or at a later time point (delayed breast reconstruction). Reasons to delay the operation include: surgeon preference, patient preference, advanced tumor requiring radiation therapy and/or chemotherapy, or because of a complication with an immediate breast reconstruction. The DIEP flap, because it can restore both the surface area and volume of a breast, is ideal for both immediate and delayed breast reconstruction. [5]
Recovery from a DIEP flap happens in stages. Most patients leave the hospital in approximately 4 days, feel capable of doing most activities on their own after 3–4 weeks, and have no surgical restrictions by 6–8 weeks. Most patients are able to return to normal activities in 3–4 months. [6]
The harvesting of abdominal fat and belly skin generally provides an aesthetic benefit to the abdomen. It is often likened to an abdominoplasty or "tummy tuck", however the two procedures have notable differences. [7]
Compared to a standard tummy tuck where excess abdominal skin and fat are removed, the DIEP flap procedure involves a longer recovery time as significant surgery is performed to the 2 vertical abdominal Rectus muscles in the process of careful "scratching" and finding the tiny blood vessel or "perforators" required to provide blood supply to the fat tissues. These are the "sit up" muscles or also known as the 6-pack muscles. They are essential muscles of the abdominal core and take some time to heal. Seven percent [10] of patients reported long-term abdominal muscle weakness. Less than 4% [11] of DIEP flap patients displayed clinically significant abdominal bulge, or hernia occurred. The reasons for this vary, though wound healing issues and sacrificing nerves seem to be correlated [11] with increased incidence of an abdominal bulge or hernia. A corrective surgery placing supportive mesh can be performed to provide strength to the abdominal wall if needed. [12]
Another benefit of this operation is that both breast are given a breast lift. This will leave permanent scarring. The extent and placement of the incisions and scars varies according to preference and skill of the surgeon. The lift is achieved by reattaching the nipple higher up on the breast and removing excess skin. The usually ample amount of tummy fat allows to the surgeon to give the patient an increase in breast size for women with smaller breasts.
DIEP flap reconstruction can be performed once only. In the case of a single mastectomy, the second breast cannot be rebuilt at a later time with a flap of fat tissue from the belly. [13] For this reason, some patients may choose to perform a mastectomy and DIEP flap reconstruction on the non-cancerous breast at the same time to reduce the chance of later development of cancer and improve the overall reconstruction outcome.
Unless a nipple sparing mastectomy was performed, the areola and nipple of the cancerous breast is discarded in this operation. If the patient chooses, new nipples and areola e are formed as a follow-up procedure through surgery and a tattoo process. Some women are satisfied without a nipple and choose to forgo nipple reconstruction and areola tattoo process.
Sensation in the nipples, much of the breast and an area surrounding the tummy tuck scar is significantly less after this operation, as microsurgery is routinely focused on vascular supply leaving the nerves untreated. [14] Although it is more technically challenging, cutaneous sensation can potentially be restored by identifying and connecting intercostal nerve branches. [15]
Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.
Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.
Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. While reconstructive surgery aims to reconstruct a part of the body or improve its functioning, cosmetic surgery aims to improve the appearance of it. A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills.
Rhinoplasty, commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.
Mammaplasty refers to a group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast. There are two main types of mammoplasty:
Abdominoplasty or "tummy tuck" is a cosmetic surgery procedure used to make the abdomen thinner and more firm. The surgery involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall. This type of surgery is usually sought by patients with loose or sagging tissues, that develop after pregnancy or major weight loss.
Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.
Breast augmentation and augmentation mammoplasty is a cosmetic surgery technique using breast-implants and fat-graft mammoplasty techniques to increase the size, change the shape, and alter the texture of the breasts. Augmentation mammoplasty is applied to correct congenital defects of the breasts and the chest wall. As an elective cosmetic surgery, primary augmentation changes the aesthetics – of size, shape, and texture – of healthy breasts.
Reduction mammoplasty is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the patient's body, the critical corrective consideration is the tissue viability of the nipple–areola complex (NAC), to ensure the functional sensitivity and lactational capability of the breasts. The indications for breast reduction surgery are three-fold – physical, aesthetic, and psychological – the restoration of the bust, of the patient's self-image, and of the patient's mental health.
Gluteoplasty denotes the plastic surgery and the liposuction procedures for the correction of the congenital, traumatic, and acquired defects and deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement of the contour of the buttocks.
The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. "Free" implies that the tissue is completely detached from its blood supply at the original location and then transferred to another location and the circulation in the tissue re-established by anastomosis of artery(s) and vein(s). This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the tissue with blood.
A seroma is a pocket of clear serous fluid. They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, and with a CT scan.
Male chest reconstruction refers to any of various surgical procedures to masculinise the chest by removing breast tissue or altering the nipples and areolae. Male chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. Transmasculine people may pursue chest reconstruction, also known as top surgery, as part of transitioning.
A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenital defects and deformities of the chest wall or, cosmetically, to enlarge the appearance of the breast through breast augmentation surgery.
Mastopexy is the plastic surgery mammoplasty procedure for raising sagging breasts upon the chest of the woman, by changing and modifying the size, contour, and elevation of the breasts. In a breast-lift surgery to re-establish an aesthetically proportionate bust for the woman, the critical corrective consideration is the tissue viability of the nipple-areola complex (NAC), to ensure the functional sensitivity of the breasts for lactation and breast-feeding.
Flap surgery is a technique in plastic and reconstructive surgery where tissue with an intact blood supply is lifted from a donor site and moved to a recipient site. Flaps are distinct from grafts, which do not have an intact blood supply and relies on the growth of new blood vessels. Flaps are done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures like breasts or jaws.
The cheek constitutes the facial periphery and plays a key role in the maintenance of oral competence and mastication. It is also involved in the facial manifestation of human emotion and supports neighboring primary structures.
Perforator flap surgery is a technique used in reconstructive surgery where skin and/or subcutaneous fat are removed from a distant or adjacent part of the body to reconstruct the excised part. The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some perforators can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle. If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example, a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator. According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the deep fascia, they don't traverse any other structural tissue. Indirect perforators first run through other structures before piercing the deep fascia.
Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.
Nipple reconstruction, specifically nipple-areola complex (NAC) reconstruction, is a procedure commonly done for patients who had part or all of their nipple removed due to medical reasons. For example, NAC reconstruction can apply to breast cancer patients who underwent a mastectomy, the surgical removal of a breast. NAC reconstruction can also be applied to patients with trauma, burn injuries, and congenital or pathological abnormalities in nipple development.
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This article incorporates public domain material from Dictionary of Cancer Terms. U.S. National Cancer Institute.