Dr Johan van Heerden educates us on DIEP flap reconstruction, the gold standard in autologous breast reconstruction.
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Evolution in breast cancer surgery resulted in more conservative, but oncological safe procedures. We live in an era where single-stage procedures for breast cancer and reconstruction can be offered to selected patients.
It’s important to keep in mind that the biology of different breast cancer types dictates an individualised approach to each patient. Multi-disciplinary management has been proven to have better outcomes.
The patient’s preferences play an important role, and it’s recommended that all options should be offered to every patient.
Breast reconstruction can be performed either immediately (with mastectomy) or delayed (after mastectomy, radiotherapy and chemotherapy). Implant and/or autologous (taken from your body) options should be discussed.
Autologous breast reconstruction
Evolution of lower abdominal flaps
Flaps are bulky pieces of tissue with their own blood supply and are much more effective for reconstruction than grafts. Since 1980 the lower abdomen skin, fat, and muscle have been used for breast reconstruction. Dr Carl Hartrampf is credited for pioneering this flap.
The pedicled (blood vessels staying attached to the body) transverse-rectus abdominis muscle flap (TRAM-flap) is transposed and used to reconstruct the breast after mastectomy. This means that a very important core muscle was sacrificed, which has a negative impact on abdominal wall function, posture, and quality of life.
To reduce function loss, newer techniques that aim to spare this important abdominal muscle was developed. Initially the lower part of the muscle with its blood vessels attached to the overlying fat and skin was removed completely (free TRAM flap) and reattached in the chest. This requires the blood vessels to be anastomosed to recipient vessels in the chest for the transplanted tissue to survive. This is also known as microsurgical free flap procedures.
In 1989, the DIEP flap was introduced; Doctors Koshima and Soeda are credited for starting this marvellous revolution in breast reconstruction. DIEP stands for Deep Inferior Epigastric Perforator. This is the specific blood vessels supplying the lower abdominal fat and skin. These blood vessels follow a tortuous course through the rectus muscle. Improved skills and meticulous technique allowed plastic surgeons to carefully dissect these vessels, preserving the nerve and blood supply to the remaining functional muscle.
Pros and cons of the DIEP flap
Most patients can qualify for this procedure if they are medically fit and preferably non-smokers. Minimal pain and discomfort may remain, but the risk of abdominal hernias, bulging, and major discomfort are reduced significantly. Scarring on the abdomen may be a problem in a very small percentage of patients and the additional pain of a donor site may not be appealing to everybody.
One of the major drives for patients to request this reconstruction is the fact that an abdominoplasty (tummy tuck) procedure is part of the package.
Studies looking at quality of life have also reported very high satisfactory rates with the DIEP flap breast reconstruction. Though, it’s imperative to consult with a plastic surgeon that performs DIEP flaps on a regular basis.
The procedure time is significantly longer compared with implant reconstruction and due to the risk of DIEP flap loss due to blood clots, the patient needs to be monitored very closely post-operative, spending a few days in ICU and another few in the ward. The recovery period is similar to most reconstructive procedures.
DIEP flaps can be utilised to replace only the breast volume where a skin-sparing mastectomy was performed. These approaches give the most natural and aesthetically pleasing results. If a nipple- and skin-sparing mastectomy wasn’t performed initially, a nipple-areola reconstruction can be offered to the patient. This can be performed at a later stage and even under local anaesthetic.
Final thought
The trauma of being diagnosed with breast cancer is very overwhelming. Feeling whole again is the goal and combatting the fear of the mastectomy procedure. Obtaining natural breast reconstruction results are possible and the DIEP flap has proven itself to be a worthy option in the armamentarium of the plastic surgeon.
References
- State of the Art and Science in Postmastectomy Breast Reconstruction – Plastic and Reconstructive Surgery, April 2015, Volume 135, Number 4, 755e – 771e
- Indications and controversies for Abdominally Based Complete Autologous Tissue Breast Reconstruction – Clinics in Plastic Surgery, January 2018, Volume 45, 83-91
- Nelligan’s Plastic Surgery, Volume 5 – Breast, Chapter 16 & 18, 3rd Edition
- Long-term Follow-up of Quality-of-Life following DIEP Flap Breast Reconstruction – Plastic and Reconstructive Surgery, May 2016, Volume 137, Number 5, 1361 – 1371
MEET THE EXPERT – Dr Johan van Heerden
Dr Johan van Heerden is a plastic and reconstructive surgeon based at Cintocare Hospital, Pretoria and is part of the multi-disciplinary breast cancer team at Life Groenkloof Hospital. He recently passed the Certificate of Competence in Breast Cancer with The European School of Oncology.
Header image by Freepik