Breast reconstruction with the Deep Inferior Epigastric Perforator (DIEP) free flap is a sophisticated surgical technique that has become a gold standard for autologous breast reconstruction. This comprehensive guide aims to provide in-depth information on DIEP free flap reconstruction, covering indications, risks, recovery, and potential complications to empower women considering this transformative procedure.

Introduction

Breast reconstruction is a critical aspect of the healing journey for women who have undergone mastectomy. The DIEP free flap procedure is an advanced reconstructive technique that utilises the patient’s abdominal tissue to recreate a natural-looking and feeling breast. Understanding the nuances of this procedure, including its indications, associated risks, recovery process, and potential complications, is essential for individuals considering breast reconstruction.

Indications for DIEP Free Flap Reconstruction

1. Post-Mastectomy Patients:
   – DIEP free flap reconstruction is indicated for women who have undergone mastectomy and desire a more natural and permanent solution for breast reconstruction.
   – This procedure is particularly suitable for individuals who want to avoid the use of implants and have sufficient abdominal tissue for the flap.
2. Desire for Autologous Reconstruction:
   – Women who prefer the use of their own tissue for reconstruction, providing a more natural look and feel, often choose the DIEP free flap over implant-based options.
3. Adequate Abdominal Tissue:
   – Successful DIEP free flap reconstruction requires an adequate amount of lower abdominal tissue. Candidates should have excess skin and fat in the abdominal area – although too much fat is associated with delayed wound healing. Generally speaking, A/Prof Marucci prefers a patient’s BMI to be below 33 and with a sufficient laxity of skin and soft tissue in the lower abdomen for there to be tension free wound closure.
4. Healthy Lifestyle:
   – Candidates for this procedure should be in good overall health and not smoke, as smoking can compromise the blood supply to the flap and affect the success of the reconstruction.

Practical Details of DIEP Flap Breast Reconstruction

Every surgeon has a slightly different technique for DIEP flap breast reconstruction. Here is a rough outline of A/Prof Marucci’s techniques and recommendations.

Before the Surgery

• You would have been given a form to have a special CT scan at Lumis Radiology, Level 2 St George Private Hospital at Kogarah. This angio-CT scan provides a roadmap for the blood vessels in your abdomen, to make harvesting the flap from the tummy tuck area faster and more accurate. This CT must be performed a few weeks before the surgery
• You will be told a few days before the surgery when to be at the hospital and when to stop eating anddrinking

The Surgery Itself

• On the day of the surgery you will be checked into the hospital. You will meet the anaesthetist
• A/Prof Marucci will draw the surgical plan on you before you go into the operating theatre. You will go into the operating theatre for the procedure
• The surgery is performed under general anaesthesia – you will be completely asleep. Antibiotics will be started. A catheter will be placed in your bladder to measure your urine output (and this means you don’t have to get out of bed or use a pan the night of the surgery). Drips will be placed in veins and arteries
• A/Prof Marucci will then perform the breast reconstruction with the surgical team and specialised nursing staff. Basically, you have a tummy tuck, but instead of that tissue being thrown away, the skin and fat is isolated on an artery and vein. The skinand fat muscle are taken out of the body with the artery and the vein supplying that tissue, and moved to the breast area where an artery and a vein are found behind a rib. Sometimes a small amount of muscle is also taken. The artery from the tummy is joined to the artery behind the rib, and the vein to the vein using microsurgery. The blood vessels are 2 to 3 mm in diameter.
• The tummy wall is sometimes reinforced with mesh to stop you getting a bulge or a hernia. Drains are placed under the reconstructed breast and under the tummy skin. Drains are hollow tubes about as thick as your little finger that drain fluid into a small cannister. You will be shown how to measure the drain output after the surgery.
• The remaining upper tummy skin is stretched down over where the flap tissue has been removed, and a new position is made for the belly button (the operating bed will be flexed or jack-knifed to make this stretching possible)
• Dissolving sutures are used to suture the new breast into position, and also to close the lower abdominal wound which goes from hip to hip. Non dissolving stitches are often used around the belly button and they come out 2 weeks later
• Paper tape (Steri-Strip) is placed on the breast wounds. A plastic dressing called Comfeel is placed on the lower tummy wound, and a large band-aid is placed over the belly button. A binder is placed around your tummy – this is like a stretchy corset which does up in front with Velcro.
• You will then be woken up and taken to Intensive Care to recover from surgery

After the surgery

• In intensive care, the new reconstructed breast will be inspected every hour for the first 2 days to make sure there are no concerns with the circulation to the flap. If either the artery or the vein block off, you would need to go straight back into the operating theatre to unblock the vessels. The chances of this happening are small – less than one in twenty. If the circulation can’t be re-established, the flap would die and you would need some other form of breast reconstruction another day. The chances of this happening are EXTREMELY small – less than one in a hundred
• The local anaesthetic used during the surgery will last for many hours. After that, you will be given stronger painkillers either through the drip or in tablet form
• The catheter in your bladder is removed the morning after surgery, and you can sit out of bed and go to the toilet as normal
• The drains stay in until they are draining less than 30 ml per day for 2 days in a row. Most patients stay in hospital for 4 or 5 days and may go home with one or two drains (which are removed the following week)
• You can get out of bed and have a shower a day or two after the surgery even with the drains in
• It is common for there to be bruising of the reconstructed breast and tummy. Initially the skin is purple, then it goes green/yellow
• Once you go home, plan on taking it easy for a few weeks. You can potter around at home.
• Most patients are driving within 2 weeks after surgery
• You can’t lift anything heavier than 3 litres of milk for 4 weeks after the surgery
• No swimming and no exercise for at least 4 weeks. Nothing “for” exercise (you can walk – but not for exercise)
• It takes a few months for everything to settle down after the surgery. The key thing is: if any problems or any concerns, contact A/Prof Marucci via the rooms
• This is a significant surgery involving almost a week in hospital. Six months after this procedure, most patients require some minor “touch up” surgery to get the breast shape and size just right. Once the breast shape and size are okay, then a nipple reconstruction can be performed. All these later surgeries are day-only procedures with rapid recovery

Before and After Photos

Here is a patient who had a left breast reconstruction with a free DIEP flap and later nipple reconstruction by A/Prof Marucci.

More of A/Prof Marucci’s before and after photos can be seen in the image gallery.

Risks Associated with DIEP Free Flap Reconstruction

1. Flap Failure:
   – The most significant risk associated with DIEP free flap reconstruction is the potential failure of the blood supply to the transferred tissue. The blood vessels which are joined together under the microscope are around 2 – 3mm is diameter. If either the artery or the vein block off, the circulation within the flap will cease and urgent action is required to re-establish blood flow. The chances of having to go back to the operating theatre are low (well less than 5%). The chances of not being able to re-establish circulation (in which case the flap would die) is extremely low – well less than 1%. Careful surgical technique and meticulous monitoring are crucial to minimise this risk.
2. Prolonged Surgery Time:
   – The DIEP free flap procedure is more time-consuming than implant-based reconstruction. Prolonged surgery time can increase the risk of complications, such as blood clots in the legs (Deep Venous Thrombosis – DVT) and infections.
3. Abdominal Wall Weakness:
   – Harvesting tissue from the abdominal area may lead to temporary abdominal weakness. However, the risk of abdominal wall weakness is generally lower with the DIEP flap compared to other flap techniques. This weakness may result in a “bulge” or sometimes even a hernia, which may require surgical repair
4. Seroma Formation:
   – Drains are inserted into the wounds, and these drains stay in until they stop draining. Even after the drains are removed, some patients will accumulate fluid under the wounds. This fluid accumulation, known as seroma, can occur at the donor and recipient sites. Regular monitoring and drainage procedures may be necessary to address this issue.
5. Changes in Sensation:
   – It is normal for their to be changes in sensation both in the reconstructed breast and in the lower abdominal area where the flap was harvested from. Feeling will improve over time but a permanent change in the feeling of the breasts and lower abdomen is common.

Recovery Process after DIEP Free Flap Reconstruction

1. Hospital Stay:
   – Patients typically stay in the hospital for 4 -5 following DIEP free flap reconstruction to ensure close monitoring and immediate response to any potential issues.
2. Limitations on Movement:
   – Patients are to wear the abdominal binder for 4 weeks after surgery. Patients are advised not to lift anything heavier that 3 Litres of milk for 4 weeks after the surgery. No swimming or exercise until given the green light by A/Prof Marucci.
3. Gradual Resumption of Normal Activities:
   – Patients are in hospital for roughly the first week and need to take it easy the second week. Most patients are able to shower normally 2 or 3 days after the surgery. Patients are usually driving within 2 weeks of surgery. A/Prof Marucci advises patients to take 3 to 4 weeks off work. All going well, patients should be back doing everything they want to do 4 weeks after surgery with no restrictions.
4. Emotional Support:
   – Breast reconstruction is not only a physical but also an emotional journey. Emotional support from friends, family, and the wonderful breast care nurses is crucial during the recovery period.
5. Revision Surgery:
   – All patients need some form of revisional surgery 6 months after the DIEP flap. This is usually minor and day only surgery to improve the appearance of the reconstructed breast – usually either liposuction, fat grafting or a skin excision to improve the symmetry. Once the breasts a symmetrical, then a nipple reconstruction can be performed, and later tattooed to give an even more realistic result.

Complications of DIEP Free Flap Reconstruction

1. Fat Necrosis:
   – Some areas of the transferred DIEP flap may lack adequate circulation to survive. Fat necrosis, the death of fat tissue, can occur in the reconstructed breast, affecting the aesthetic outcome. Sometimes some of the transferred skin doesn’t survive as well as the underlying fat. Often, these areas heal with a scar after simple dressings with Vaseline and gauze. Sometimesrevision surgery may be needed to reconstruct the lost tissue.
2. Partial or Complete Flap Loss:
   – Despite meticulous surgical technique, there is a risk of partial or complete flap loss. Immediate intervention is necessary to salvage the reconstruction if this occurs. This potential complication has been covered above under “Flap Failure” in the “Risks Associated with DIEP Free Flap Reconstruction”.
3. Infection:
   – Infections can occur at the donor or recipient sites, in the skin, in the deeper tissues, in the lungs or in the bladder. Antibiotics are routinely given at the time of surgery to decrease the risks of post operative infections.
4. Delayed Wound Healing:
   – Some patients may experience delayed wound healing, particularly along the lower abdominal wound. Usually delayed wound healing is minor and can be managed with simple Vaseline and gauze dressings.
5. Asymmetry Issues:
   – Achieving perfect symmetry between the reconstructed breast and the natural breast is unfortunately not possible. Every effort is made to try to make the breasts as symmetrical as possible.

Conclusion

DIEP free flap reconstruction is a sophisticated and highly effective option for women seeking autologous breast reconstruction after mastectomy. Understanding the indications, risks, recovery process, and potential complications is crucial for making informed decisions and managing expectations. By providing comprehensive information, this guide aims to empower women considering DIEP free flap reconstruction to navigate the complexities of the procedure with confidence, ultimately enhancing their physical and emotional well-being.

It is also important to choose an experienced surgeon to perform your breast reconstruction. Look for a surgeon who is a Fellow of the Royal Australasian College of Surgeons (FRACS) and is a member of the Australian Society of Plastic Surgeons (ASPS) as well as the Australasian Society of Aesthetic Plastic Surgeons (ASAPS). A/Prof Marucci has a FRACS in Plastic and Reconstructive Surgery. He is on the Education Committee of ASPS and is on the Board of ASAPS. A/Prof Marucci is registered a specialist in Plastic and Reconstructive surgery with AHPRA.