DIEP Flap for Breast Reconstruction: The New Gold Standard

Although both men and women develop breast cancer, the disease is by far more common in women. Increasingly, breast cancer is treated by removing the lump (a lumpectomy) or parts of the breast, followed by chemotherapy and/or radiation. But for breast cancers that require a mastectomy, the trauma of diagnosis is increased by a sense of loss for a body part that, for many, symbolizes womanhood.

For microsurgeons Robert M. Whitfield, MD, and John B. Hijjawi, MD, Medical College of Wisconsin Assistant Professors of Plastic and Reconstructive Surgery, reconstructing the breast after mastectomy is a very significant and special part of their practice. The doctors practice together at the Froedtert & The Medical College of Wisconsin Plastic and Reconstructive Surgery Clinic in the Wisconsin Athletic Club building.

The decision to have breast reconstruction surgery after a mastectomy is more complicated than it seems. Only half of the women who have mastectomies even seek reconstruction. Why?

"Sometimes it's a lack of information; sometimes it's just a personal choice. Sometimes you hear 'breast cancer,' and it's a lot to digest - they're talking about chemotherapy, radiation, and different types of surgeries," says Dr. Hijjawi. "Some people would rather do it one step at a time, deal with the cancer, then consider reconstruction. Time isn't an issue. I've even had a patient who had a reconstruction 15 years after her initial mastectomy."

"Many times people are not informed well about their options," notes Dr. Whitfield. "It's a federal law that every woman can have a breast reconstruction. There is no insurance carrier who can say, 'you can't have this.' And it doesn't matter if you change carriers."

Drs. Whitfield and Hijjawi are two of fewer than 40 surgeons in the US who routinely perform a new breast reconstruction procedure called DIEP (Deep Inferior Epigastric Perforator) flap surgery. Not only is it rare to have two doctors who specialize in this surgery working at the same hospital, but the doctors literally work together on each surgery, sharing and exchanging roles throughout the complicated procedure.

Microsurgery Makes New Procedures Possible
For twenty years the TRAM (Transverse Rectus Abdominis Myocutaneous) flap has been the standard of care. In this procedure a section of abdominal muscle and fat is used to reconstruct the breast or breasts that have been removed.

The use of autologous tissue (tissue from the patient's own body) creates a more natural-looking and natural-feeling breast, and the use of operating-room microscopes pushed the technology even further. "Once we were able to hook blood vessels together under the microscope, we started doing a procedure called a 'free flap'. It is relatively easy to do, but it still sacrifices abdominal muscle," explains Dr. Whitfield. As a result, many patients experience weakness and herniation in the area.

Advantages of the DIEP Flap
The new DIEP flap operation has distinct advantages over previous methods, primarily because it does not require muscle to be taken, only fat, Dr. Whitfield explains. "The same tissue that would be harvested for a 'tummy tuck' (a cosmetic procedure that reduces the fat in the abdomen) is used to form the new breast. All you need is enough abdominal tissue to have the procedure done. At one year after having the DIEP flap procedure, the abdomen will retain approximately 80% of its muscle function - based on studies done, this is not usually noticeable by the patient.

"The benefit, obviously, is that if we don't harvest the muscle then we don't cause any disruption - the activities of daily living that were once interrupted by having a TRAM flap done are not an issue for us any more.

"We don't have as much problem with bulge formation or hernias because we're making a limited incision, and the layers of the abdominal wall remain intact. That tends to be a big issue, especially as women get younger at the diagnosis of breast cancer. They still want to go on and have children and if it's at all possible we want them to have the opportunity to do that without back or abdominal wall dysfunction."

Dr. Hijjawi points out another advantage of DIEP flap surgery. "It can be done even for patients who have had previous abdominal surgeries, including C-sections," he says. "Situations in which you can't have a DIEP flap surgery are rare; in fact, there are very few times in which it can't be safely done."

Still, Drs. Whitfield and Hijjawi only perform the procedure when it makes the most sense to do so. "We're not zealots in that we will try to do every single patient as a DIEP flap," says Dr. Whitfield. "If the anatomy is not appropriate we will never risk the reconstruction using that technique. I had one case in which I performed a DIEP flap on one breast and a free TRAM on the other, because that's what was called for in that particular situation."

The DIEP Flap: A Three-Phase Procedure
Each DIEP flap breast reconstruction has three phases. During the first phase, the surgeons find the appropriate perforator vessel that will be used to supply blood flow when the fat is transferred to the breast area. "A perforator is essentially a blood vessel that comes up through the muscle; it supplies the skin and fat overlying the muscle," Dr. Whitfield explains.

"In the operating room, we look at all these vessels thoroughly and decide which we can use. We divide the blood vessels, take them up, and attach them to either the blood vessels underneath the breastplate or to those in the armpit area - we normally hook blood vessels up to the internal mammary artery vein underneath the breastplate."

Then the abdominal fat is harvested without interrupting the integrity of the muscle or fascia (the muscle covering). "There is no internal derangement of tissue because everything is taken off just as you would do a tummy tuck," Dr. Whitfield notes.

"This is really important to us," Dr. Hijjawi adds. "This is cancer reconstruction, there's no question about it. But our goal is that, to the greatest extent possible, after DIEP flap surgery the abdomen looks as good as it does for someone who comes in for a straight cosmetic tummy tuck. In fact, the bikini-line incision is the same. "

The abdominal fat is then carefully shaped to form a breast mound, its blood supplied by the newly attached vessel. This precision transfer and attachment is made possible only by the advent of microsurgery.

But the procedure can take a long time, Dr. Whitfield notes. "If you identify the largest perforating vessel quickly, the operation might take about 4 hours. If you have to search and search, it might take 6 hours, but we feel the time investment is more than adequate based on what we can provide."

"We don't have dinner plans the nights we do these cases," says Dr. Hijjawi. "It's going to take as long as it takes, and there's no evidence that there's a down side to having a longer surgery. We like to move expeditiously but if it's a matter of that flap, and of a quality reconstruction, we'll take as long as we have to."

Somewhere between one and three months after the initial breast mound is formed, the second phase of breast reconstruction begins. The purpose of this procedure is to create symmetry so the breasts look as much alike as possible. This might involve reducing one breast, a lifting procedure, reshaping the reconstruction side, or a combination. For instance, most women will have some natural breast sagging that comes with age. If this is the case, part of the process includes a breast reduction and reshaping on the non-reconstructed breast.

The third phase is nipple reconstruction. "There are many, many ways to do this," Dr. Whitfield says. His technique involves making a small flap of soft tissue around the central portion of the breast, where the original nipple would normally be.

The final element in this process is not surgical but is an important part of the final modification for many women: the areola, the colored part of the breast around the nipple, is tattooed to look like the unaltered breast. A medical tattoo artist comes to the facility weekly.

Time Well Spent
Patients who have had DIEP flap surgery spend less time in the hospital than those who have had more traditional surgeries, says Dr. Whitfield. "There is a decreased hospital stay by far. Almost all our patients go home in 3 to 5 days. They require less pain medicine because we haven't cut any muscles, and we haven't done anything to create an environment where there's going to be spasm, which can be a problem with TRAM flaps."

Drs. Whitfield and Hijjawi typically perform one or two DIEP flap operations every week. "Of the cases we do, about 95% of the time everything is fine," says Dr. Whitfield. "If 5% or so have a problem, usually with a vein, we take them back to the operating room. Of those, we salvage about 80%.

Although a reconstructed breast will have some scarring and tissue discoloration, women who have the surgery are usually very pleased with the results. "They're happy with their body image, and they can feel comfortable in their clothes," Dr. Whitfield says. "As plastic surgeons, we should all be able to achieve that for our patients."

A Tradition of Excellence
In many environments this procedure is not available, Dr. Whitfield says. "In fact, it's not offered in most places - the time investment is the problem. You might be investing 10 hours to do one case. But we've joined a practice that, for 24 years, has done high-volume microsurgery. The first fingers ever reattached in Wisconsin, the first hand ever reattached in Wisconsin, were reattached here by our senior partners."

And the quality of care at Froedtert & The Medical College of Wisconsin is exceptional, say the doctors. "None of our patients need to go to the ICU," Dr. Whitfield says. "There is a tradition of excellence here. When you go to the regular floor at Froedtert Hospital, the quality of the nursing care is exceptional. And our anesthesiologists do a very good job. They take care of everybody very, very well. We've haven't had any anesthetic complications from any of our cases."

Drs. Whitfield and Hijjawi say that in their practice, the patient's requirements always come first. The patient and the doctor decide together, based on the woman's needs, what type of surgery would give the patient the optimum results, and design their plan accordingly.

"That's a big, big part of breast reconstruction," concludes Dr. Hijjawi. "To a patient, the most important thing we can ask is, 'When are you happy'? For some women, having nothing done is the right thing to do. For other women, just having the mound made and saying 'that's fine, I'm done,' is the right thing to do. Other women go through the whole process. And that, for them, is the right thing to do. We're here to facilitate that."

Eileen Early, RN, BSN
HealthLink Editor

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.