DIEP Flap Myths

DIEP flap surgery is not considered experimental. Since fewer surgeons have been trained to perform perforator flap breast reconstruction than other methods of reconstruction, TRAM flap and implant reconstructions are more widely available. The DIEP flap was developed in the late 1980s and has been used extensively for breast reconstruction since the early 1990s. In fact, Dr. Greenspun is an author of a published scientific paper reviewing almost 4000 perforator flap breast reconstructions.

When performed by experienced surgeons, DIEP flaps and other perforator flap breast reconstructions are not riskier than other methods of breast reconstruction. Although perforator flap surgery can take longer in the operating room than implant reconstructions, published studies in peer-reviewed journals have found that, in the hands of an experienced microsurgeon, the time it takes to perform a perforator flap reconstruction is generally rewarded with excellent short- and long-term results. In fact, better surgical outcomes have been noted in a number of regards. For example, the chances of developing a hernia following a TRAM flap is reported in the medical literature to range from about 3% to about 30%, but about 1% following a DIEP flap.

Unlike surgery on the intestines, gallbladder, or other internal organs (such procedures are known as “intra-abdominal”), perforator flap breast reconstruction takes place in the more superficial layers of the body. While long intra-abdominal surgeries are often associated with difficult and prolonged recovery, perforator flap surgery generally means a relatively rapid recovery. Although perforator flap surgery takes significantly longer to perform than tissue expander/implant reconstruction, in many ways the body’s response to undergoing a DIEP flap breast reconstruction more closely resembles the response to a breast reduction or a tummy-tuck than to major intra-abdominal surgery. It is not uncommon for patients who undergo perforator flaps to be out of bed and sitting in a chair on the first day after surgery, and to be walking around by the second day following surgery.

Every surgical procedure carries some degree of uncertainty and risk. However, studies published in peer-reviewed journals such as the Journal of Plastic and Reconstructive Surgery, Journal of Reconstructive Microsurgery, Annals of Plastic Surgery and British Journal of Plastic Surgery have repeatedly demonstrated the safety of DIEP flap breast reconstruction.

Data published by the implant manufacturer Mentor in their patient labeling “Saline-Filled Breast Implant Surgery: Making an Informed Decision” outlines the findings of their study of saline filled implants required by the United States Food and Drug Administration (FDA). The data below have been extracted from the publication, which is available in its entirety on the website of the FDA along with the publications for other approved breast implants.

You can compare the safety of DIEP flap surgery to implant reconstruction by looking at the published data below:

Your Rights section of this site.(Adapted from Mentor publication “Saline-Filled Breast Implant Surgery: Making an Informed Decision” – available through the FDA)

(Adapted from “A 10-Year retrospective review of 758 DIEP Flaps for Breast Reconstruction” published in Plastic and Reconstructive Surgery)

Comparison to published rates for DIEP flap complications shows that women who undergo reconstruction with an implant are up to 7 times more likely to have an unanticipated surgery to address a complication of their reconstruction. The risk of complications associated with the use of an implant is even higher when radiation is part of a woman’s treatment.

Cutting across the fibers of a muscle (which will cause the muscle to go into spasm), or over-stretching a muscle with a tissue expander can cause significant pain and discomfort. Since it is not necessary to cut across muscle fibers or put muscle under stretch with perforator flap breast reconstruction surgery, it is not surprising that women who undergo these procedures are quite comfortable after surgery. It is not uncommon for patients to report that they had “much less pain” after their DIEP flap than after their C-section. Studies have show that women who undergo DIEP flaps have less postoperative pain and discomfort and more rapid recovery than women who undergo TRAM flap surgery.

Although some surgeons who perform DIEP flap surgery frequently convert to a free TRAM flap procedure during surgery, Dr. Greenspun relies upon preoperative imaging of blood vessels to plan surgery in advance, and thus avoid the need the need to “change-over” to a muscle-sacrificing procedure during surgery. Dr. Greenspun pioneered the use of MRI for imaging of perforator flap blood vessels, and he has published extensively on the topic. In Dr. Greenspun’s opinion, rarely, if ever, should conversion to a free TRAM flap be necessary.

Most women who have had prior abdominal surgery (including C-sections, hysterectomies, gall bladder removal, laparotomy, appendectomy, tubal ligations, laparoscopic and even some liposuction procedures) are still candidates for DEIP flap surgery. Occasionally, prior surgery may have damaged the blood vessels needed for a DIEP flap, and some surgeons therefore routinely suggest that abdominal perforator flap surgery is contraindicated in patients with a history of previous abdominal surgery. The development of reliable preoperative blood vessel imaging means that it is now possible to locate suitable vessels and perform DIEP flap breast reconstructions in almost all women who have had prior surgery. In situations when all suitable abdominal vessels have been damaged by prior surgery, an alternate perforator flap such as a GAP or LAP flap can generally be selected for breast reconstruction.

Many thin women are candidates for a DIEP flap breast reconstruction. Even very thin women are often candidates for this type of breast reconstruction because breast and abdominal size tend to be proportionate. We have found that even women who have previously been told that they are too thin to have a DIEP flap, have successfully been reconstructed with DIEP flaps. Preoperative imaging of blood vessel helps to make this possible. When a woman’s abdomen cannot provide enough tissue to reconstruct breasts of her desired size, it is usually possible to reconstruct the breasts using a flap taken from the buttocks (GAP), “love handle” area (LAP) or inner thigh (TUG).

Being overweight is not itself a contraindication to perforator flap breast reconstruction. Following a comprehensive medical workup and evaluation, we routinely operate on patients who are overweight. Some complications occur at a higher rate in obese patients, however, with appropriate planning, perforator flap surgery can still be an option for breast reconstruction.

Although both the TRAM flap and the DIEP flap use soft tissue from the lower abdomen to reconstruct a breast, there are major differences in the way these two procedures affect the abdomen after surgery. Since TRAM flaps remove muscle from the abdominal wall, and DIEP flaps do not, the former are associated with significantly more postoperative pain and a longer period of recovery. Women reconstructed with TRAM flaps have been found, in the long term, to suffer from diminished trunk strength and a much higher incidence of hernias and bulges than women who undergo DIEP flap breast reconstruction. Because muscle is not sacrificed with a perforator flap, strength is well preserved.

There is no particular age at which a woman is too old to undergo perforator flap breast reconstruction. A woman’s age will be one of many factors that determine whether she is a good candidate for a DIEP or other perforator flap breast reconstruction. In general, a woman’s overall heath is a much more important measure of her suitability for surgery than her age.

The 1998 Federal Breast Reconstruction Law (also known as the Women’s Health and Cancer Rights Act) requires insurance providers to provide coverage for breast reconstruction surgery following mastectomy as well as any surgery necessary to create symmetry in either breast. Additional surgery, including replacing an implant used in breast reconstruction with a DIEP or other perforator flap, needed to address problems with an implant reconstruction is considered medically necessary. Our office can help you to secure authorization for such surgery.

Most plastic surgeons do not perform perforator flap breast reconstruction because of its complexity. These microsurgical procedures are technically difficult and time consuming. The best success rates and the highest degree of efficiency are achieved when these reconstructive procedures performed by a team of experienced microsurgeons. There are very few microsurgical breast reconstruction teams committed to such an endeavor. If you do not have access to doctors who perform perforator flap reconstruction in your community, your insurance carrier typically is obligated to find you a surgeon who can provide you with the reconstruction method of your choice. This means you may be granted a “gap-in-coverage” or “out-of-network” exception to see a specialist who can provide the service for you.
Our office is accustomed to taking care of out-of-town patients who come to us to undergo DIEP flap or other perforator flap breast reconstructions in New York City or Greenwich Connecticut. We can help coordinate your travel plans and stay in either location. If you have recently been diagnosed with breast cancer, our staff can help arrange prompt consultation with one the breast oncologic surgeons with whom Dr. Greenspun works. If necessary, we can also arrange consultations for you with medical and radiation oncologists who, together with Dr. Greenspun and your breast surgeon, will develop a comprehensive cancer treatment plan.

As a result of the Women’s Health and Cancer Rights Act of 1998, health insurance carriers are required to cover the expense of breast reconstruction following mastectomy. This Federal Act also protects a woman’s right to select the type of reconstruction she wishes to undergo. Most insurance plans are happy to have patients pursue expander/implant reconstructions and the older methods of flap reconstruction such as the TRAM flap, as they generally have network-participating surgeons who perform these procedures. An insurer cannot, however, deny coverage for a breast reconstruction procedure such as a DIEP flap simply because they do not have a network-participating physician willing or able to perform the breast reconstruction procedure a woman wishes to have.
Our office has extensive experience obtaining out-of-network exceptions for women who wish to undergo perforator flap breast reconstruction but do not have access to a network-participating physician who performs these procedures. We are often able to obtain these exceptions both for patients with HMO plans and for those who have out-of-network benefits but prefer to try to stay within their networks. In all cases, we will work closely with you to minimize your out-of-pocket expenses for surgery.

Although the websites of many plastic surgeons describe DIEP flap breast reconstruction, most plastic surgeons do not routinely perform these or other types of perforator flap breast reconstruction even if they perform microsurgery. In part, this is because most plastic surgery training programs do not provide significant exposure to these complex reconstructive procedures, but do provide extensive training in implant and TRAM flap reconstructions.

If you are considering perforator flap breast reconstruction, you may want to find out more information about your doctor’s experience with these procedures. Here are some useful questions to consider asking:

• Are you certified by The American Board of Plastic Surgery® or The Royal College of Physicians and Surgeons of Canada®?
• Have you had additional training in microsurgery and perforator flap breast reconstruction after residency?
• What types of breast reconstruction do you most commonly perform?
• How many DIEP flap procedures have you performed?
• How many DIEP flap procedures did you perform last week/month/year?
• How often do you convert a DIEP flap to a free TRAM flap?
• What is your success rate?
• Who, if anyone, will your assistant surgeon be?
• Who will be monitoring my flap after surgery?

It is also a good idea to review a significant number of postoperative photographs of the surgeon’s patients who underwent perforator flap breast reconstruction. This will help you to get a sense of what reconstructed breasts look like and to know more about your doctor’s results in particular.