Breast reconstruction with abdominal flap (DIEP)
The breast reconstruction is a psychologically important step for any patient who has undergone a mastectomy. The difficulty of this breast plastic surgery will depend on the state of the tissues, more or less altered by the breast cancer treatment (surgery, radiotherapy, chemotherapy...).
The DIEP (Deep Inferior Epigastric artery Perforator) flap breast reconstruction technique can be used in the most complex cases, by displacing a cutaneous-adipose flap from the abdomen, vascularized by the inferior epigastric pedicle.
What are the indications for breast reconstruction with dorsalis major in Paris?
The principle of this flap is to remove the skin and abdominal fat below the navel, along with the blood vessels that feed them. These vessels are sectioned, and reconnected to the internal mammary vessels under a microscope.
The DIEP flap therefore requires perfect mastery of microsurgery.
This is a breast reconstruction technique that Dr Christelle Santini recommends for the most complex cases, in particular when the skin of the thorax is altered and cannot support the fitting of breast prostheses.
The DIEP flap is indicated as follows:
- If the contralateral breast is large
- If the anatomy of the belly lends itself to it, with a clear excess of abdominal skin below the navel.
As the volume of the flap is large, it is generally not necessary to associate a prosthesis with it: it is therefore a 100% natural reconstruction, with no foreign material. The breast reconstructed with a DIEP flap is supple and voluminous, and will follow the contralateral breast's evolution over time, like the rest of the body, since no implant is present.
Harvesting this tissue flap from the lower abdomen therefore involves a horizontal scar, located above the pubic hair. The skin of the flap corresponds to that of a cosmetic abdominoplasty. The final scars are identical to those of a cosmetic abdominoplasty. This explains the popularity of this technique.
The great advantage of DIEP is that, unlike TRAM Transverse Rectus Abdominis Myocutaneous breast reconstruction, it does not involve abdominal muscle loss, since only skin and fat are removed, without affecting the muscular plane.
What to do before the DIEP flap breast reconstruction procedure?
In some cases, Dr. Christelle Santini recommends an initial consultation even before the planned mastectomy. This enables the patient and the care team to adapt the treatment to the patient's needs.
At least 15 days before surgery, a clinical and aesthetic examination will again be performed.
Smoking cessation is recommended one month before and one month after surgery (smoking can delay healing). No medication containing aspirin should be taken in the 10 days prior to surgery.
How is the DIEP flap breast reconstruction procedure performed?
DIEP flap breast reconstruction is performed under general anesthesia. The procedure lasts from 4 to 7 hours.
An abdominal angioscan is performed preoperatively to identify the perforating vessel of good caliber, which will serve as the nutrient pedicle for the flap.
A strip of skin below the umbilicus is removed, along with its fat, through a long horizontal incision above the pubic hair.
The flap is removed with its vessels.
These are then sutured to the internal mammary vessels and sometimes to the armpit vessels, using microsurgical techniques.
The mastectomy scar is reopened and the flap is placed and shaped. The abdominal skin is then sutured.
Drains are inserted at the end of surgery to aspirate post-operative secretions and reduce the risk of hematoma.
What to do after DIEP breast reconstruction?
Pain varies in intensity. It is systematically managed as a preventive measure and adapted to your case. Drains are removed between the third and seventh day. The duration of hospitalization is approximately 7 to 10 days, corresponding to the monitoring phase. You will need to wear an abdominal girdle for a month, day and night, and a contention bra for at least 6 weeks.
The major risks of this procedure are occlusion of the microsurgically sutured vessels for the first 10 days, leading to fears of complete reconstruction failure or phlebitis.
Tissue vitality is therefore monitored when dressings are changed.
What is the outcome of breast reconstruction with a DIEP flap?
The reconstructed breast is supple and, in principle, provides sufficient volume without the need for a breast implant. Over time, it tends to take on the shape of the contralateral breast. A final operation may be necessary a few months later to symmetrize the contralateral breast and reconstruct the areola with its nipple.
It is important to warn patients in advance of the creation of an additional scar below the navel, but it will remain hidden by undergarments.
All scars must be perfectly protected from UV rays for 6 to 12 months, to avoid hyperpigmentation.
Highlights of abdominal flap breast reconstruction
- Breast surgery conditionally reimbursed by social security.
- Individualized surgery for a natural look, usually without implants.
- Highly symbolic for patients, with aesthetic and psychological improvements.
DIEP flap breast reconstruction in a nutshell...
What should I do before undergoing breast reconstruction using an abdominal skin flap?
- 1 to 2 plastic surgery consultations with agreed estimate and medical photographs.
- Consultation possible before mastectomy.
- Consultation with anaesthetist, blood test, angioscanner, oncology report.
How does DIEP flap breast reconstruction work?
- Precision surgery under general anesthesia.
- 5-7 hours for abdominal flap reconstruction.
- Prostheses often unnecessary.
- Return home the next day or two.
- An elastic support bra is worn for 2 months after drain removal, and an abdominal girdle for 1 month.
What is the post-operative course of DIEP breast reconstruction?
- Absorbable skin threads.
- Follow-up with Dr Santini 7 to 10 days after breast reconstruction surgery.
- Final results after 12 to 18 months.
- Subsequent surgery on the areola may be required.