| DIEP
/ SIEA / SGAP Flap Details |
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HISTORY |
The most common method of
breast reconstruction using a patient's own tissues (as opposed
to breast implants) has been TRAM flaps. A TRAM flap involves
the surgeon removing tissue (skin, underlying fatty tissues,
and muscle) from the abdomen and using it to create the new
breast. The tissue needs a blood supply to keep it viable,
so the surgeon has to harvest the blood vessels that run through
the underlying muscle to the abdominal wall fat and skin.
Although what is really needed to form the new breast is the
skin and underlying fatty tissues, the blood vessels supplying
those tissues go through the muscle, and that is the reason
the muscle is also taken. When this type of procedure is done,
patients are left with a long scar that is very similar to
the scar that is left when a cosmetic abdominoplasty ("tummy
tuck") is performed, with the abdominal wall nicely recontoured.
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DISADVANTAGES
OF A TRAM |
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Although TRAMs are highly successful and still
a very good option for many patients, there are a few disadvantages
to a TRAM flap. Because the abdominal muscles are cut and a
portion removed, patients are left with some abdominal wall
weakness. In addition, they are also at increased risk for abdominal
wall hernias. Also, much of the discomfort many patients feel
after the surgery is not in the area of the new breast but rather
from the abdomen where the muscles were cut. |
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| DESCRIPTION OF A DIEP |
| A DIEP flap is a microsurgical technique that
many feel represents an improvement over the TRAM flap. When
a DIEP flap is harvested, the skin and underlying fatty tissues
from the abdomen are removed, but the muscle and abdominal wall
fascia are preserved and left in place. |
In a DIEP flap, what
the surgeon does instead is to microsurgically dissect
out the major blood vessels (called perforator vessels).
This illustration represents the blood vessels being
dissected from the surrounding muscle which leaves the
muscle intact. These vessels that run through the muscle
are called perforator vessels. |
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| ADVANTAGES OF A DIEP |
Because this approach leaves the
muscle wall and its overlying fascia intact, there is
much less risk of abdominal wall weakness and hernia.
In addition, patients clearly have less discomfort following
DIEP surgery as compared to a free TRAM flap. Because
of the reduced pain and fact that the muscle wall remains
intact, patients are often able to get back to their
normal daily routines more quickly than after a TRAM
flap reconstruction. Patients undergoing a DIEP flap
have essentially the same scar as those undergoing a
TRAM flap, so their abdominal wall is nicely recontoured.
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| CONTRAINDICATIONS OF A
DIEP |
|  As
with any surgical procedure, there are disadvantages to a
DIEP flap. Because it is a more complex procedure, the DIEP
flap takes longer so the patient's anesthetic is also longer.
If a patient has previously had abdominal surgery, or if the
patient does not have enough extra skin and underlying fatty
tissues in the abdomen, the patient may not be a candidate
for this type of procedure. Also, because of the complexity
of this procedure, there are only a handful of surgeons in
the country who are experienced at performing a DIEP flap.
Determining whether a patient is a candidate
for a DIEP is something the doctor must do on a case-by-case
basis. However, because this is a lengthy surgery there are
some conditions which may possibly prevent a patient from
being a candidate for a DIEP. These contraindications are
things like: |
- Insulin-dependent diabetes - affects wound healing after
surgery
- Significant cardiac or pulmonary diseases/conditions -
may preclude a lengthy anesthetic
- Significant obesity - affects wound healing after surgery
and may preclude a lengthy anesthetic
- Age - as patients get older other health conditions are
more likely to preclude a lengthy surgery or anesthetic
- Smoking - affects wound healing after surgery
- Previous abdominoplasty ("tummy tuck") - DIEP
/ SIEA cannot be done if there has been a previous abdominoplasty
- Liposuction - if a patient has previously had abdominal
liposuction it may preclude having a DIEP / SIEA
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As a general rule, most patients
who qualify for a TRAM flap will probably qualify for a TRAM
flap, with some exceptions due to the increased length of
surgery. Previous c-sections, hysterectomies, and appendectomies
do not normally interfere with a patient qualifying for a
DIEP flap. |
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| SIEA FLAP VARIATION |
| An SIEA flap is essentially
a variation on the DIEP flap. The difference is in which blood
vessels are utilized. The decision as to which blood vessels
will be used is one which is made intraoperatively by the
surgeon, based upon the patient's own anatomy. For the vast
majority of patients, the DIEP flap is the best alternative.
However, in the hands of a surgeon who is highly experienced
with perforator flaps, it may be possible to do the SIEA flap.
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