DIEP Flap Breast Reconstruction - Natural Breasts With A Tummy Tuck
By Minas Chrysopoulo, MD
DIEP flap surgery - so why all the hype? If you are a woman facing mastectomy due to breast cancer you have a decision to make: do you want breast reconstruction? If the answer is "yes", plastic surgery and particularly DIEP flap breast reconstruction, may hold the answer.
Although reconstruction cannot replace the breast(s) you were born with or allow you to breastfeed, it can restore your natural silhouette and make you feel "whole" again after mastectomy. Depending
on your health, breast reconstruction can be performed immediately after your mastectomy so you can wake up with new breasts already in place. While the cosmetic results with immediate reconstruction are generally superior (particularly when combined with nipple-sparing or skin-sparing mastectomy), reconstructive surgery can also be performed at a later time once the cancer treatment has been completed.
DIEP flap surgery represents today's gold standard in breast restoration. Advances in breast reconstruction have made it possible to use excess skin and fat from the abdomen (rather like the tissue removed during a tummy tuck) to create a new "natural" breast without the need for implants or the sacrifice of abdominal muscles. The DIEP (Deep Inferior Epigastric Perforator) flap is a sophisticated modification of an existing surgery known as the TRAM (Transverse Rectus Abdominus Myocutaneous) flap.
TRAM flap surgery is a common breast reconstruction technique that requires the rectus abdominus (sit-up) muscle to be sacrificed and moved to the upper abdomen. Unfortunately, this technique can be associated with significant post-operative pain, prolonged recovery, loss of abdominal muscle strength, abdominal bulging (or "pooching"), and even abdominal hernia.
DIEP breast reconstruction is similar to the TRAM procedure but spares the rectus abdominus muscle completely. SKIN AND FAT ONLY are removed from the abdomen, transplanted to the chest and connected using microsurgery to create the new breast. NO MUSCLE is sacrificed. As the sit-up muscle is left behind in its natural place many of the above abdominal complications are avoided and the patient essentially receives a tummy tuck at the same time. There also tends to be far less pain and a quicker recovery time because the abdominal muscles are left in place.
Knowing the significant advantages of DIEP flap surgery it is easy to understand the reason for all the hype, especially for active individuals who don't want to sacrifice the strength of their
abdomen. A breast that has been reconstructed with fat and skin will also look and feel more natural than an implant reconstruction and will last longer without the long-term risks that can be associated with implants. Unlike an implant, the reconstructed breast is warm and also ages like a natural breast.
As with all types of breast reconstruction, 2 or 3 stages performed a few months apart are often required to complete the reconstruction process and to obtain the best cosmetic result. Unfortunately, due to the complexity of the surgery very few centers in the US perform the DIEP procedure so many patients are forced to travel for the procedure. The good news is that many of these specialist centers will
accommodate out-of-state and even international patients.
So how do you find a top DIEP flap surgeon? To learn if a breast center or plastic surgeon near you offers this advanced procedure, please check the following websites:
www.diepbreastreconstruction.org/diepdocs1.htm, www.breastrecon.com/id10.html and www.diepsisters.com/diepdoctors.html
The lists on these websites seem very thorough. Having said that, currently there are only about 40 plastic surgeons in the US that perform DIEP breast reconstruction routinely.
Questions to Ask your Surgeon
Before choosing a DIEP surgeon be sure to ask the following questions:
Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon.
Do you have extensive experience with this type of surgery - How many have you performed? Preferably your surgeon will have performed over 100 procedures.
What's your success rate? Top specialist centers boast a success rate of at least 98%.
How long does the surgery take? This will vary between institutions based on experience. The most experienced surgeons typically take between 3-6 hours depending on whether one or both breast are being reconstructed (not including the mastectomies).
How often do you plan to perform a DIEP flap but end up changing the procedure to a free TRAM flap during the surgery? This should happen infrequently.
How many microsurgeons will be performing the surgery? Since the DIEP flap procedure is so technically demanding and long, it is preferable to have two microsurgeons performing the surgery rather than just one. Not only will this ensure you benefit from the expertise of two specially trained surgeons, but it will also significantly cut down the length of the procedure and anesthesia.
Do you have residents or fellows? Will they be performing any of my surgery? Some centers have surgeons-in-training known as "residents" or "fellows" that may be helping with your surgery or even performing part of it. This may or may not be something you are comfortable with considering the complexity of the surgery.
Do you "balance bill"? Centers that are in-network for most insurance plans will ask the patient to pay ONLY what's laid out by the patient's insurance plan (ie copay, deductible, etc). Other centers "accept insurance" and will often help the patient get money back from their insurance company - however, the patient is still expected to provide the difference between what the insurance pays and the doctor's fee. This is known as "balance billing". While many centers do this, some DO NOT balance bill. Make sure to ask ahead of time to avoid nasty financial surprises down the line.
Do you have Insurance Specialists on staff? Unfortunately, some patients will face difficulties in gaining access to DIEP flap specialists even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out centers that specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues.
PRMA Plastic Surgery has successfully performed over 3,000 DIEP flap breast reconstructions. We specialize in advanced breast reconstruction procedures that use the patient's own tissue. Procedures offered include the DIEP flap, SIEA flap, GAP flap, and TUG flap. We are In-Network for most US insurance plans. Patients are routinely welcomed from across and outside the USA. Connect with other breast cancer reconstruction patients at www.facebook.com/PRMAplasticsurgery
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Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon.
Do you have extensive experience with this type of surgery - How many have you performed? Preferably your surgeon will have performed over 100 procedures.
What's your success rate? Top specialist centers boast a success rate of at least 98%.
How long does the surgery take? This will vary between institutions based on experience. The most experienced surgeons typically take between 3-6 hours depending on whether one or both breast are being reconstructed (not including the mastectomies).
How often do you plan to perform a DIEP flap but end up changing the procedure to a free TRAM flap during the surgery? This should happen infrequently.
How many microsurgeons will be performing the surgery? Since the DIEP flap procedure is so technically demanding and long, it is preferable to have two microsurgeons performing the surgery rather than just one. Not only will this ensure you benefit from the expertise of two specially trained surgeons, but it will also significantly cut down the length of the procedure and anesthesia.
Do you have residents or fellows? Will they be performing any of my surgery? Some centers have surgeons-in-training known as "residents" or "fellows" that may be helping with your surgery or even performing part of it. This may or may not be something you are comfortable with considering the complexity of the surgery.
Do you "balance bill"? Centers that are in-network for most insurance plans will ask the patient to pay ONLY what's laid out by the patient's insurance plan (ie copay, deductible, etc). Other centers "accept insurance" and will often help the patient get money back from their insurance company - however, the patient is still expected to provide the difference between what the insurance pays and the doctor's fee. This is known as "balance billing". While many centers do this, some DO NOT balance bill. Make sure to ask ahead of time to avoid nasty financial surprises down the line.
Do you have Insurance Specialists on staff? Unfortunately, some patients will face difficulties in gaining access to DIEP flap specialists even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out centers that specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues.
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