Prof. Fabio Santanelli di Pompeo

DIEP Flap Procedure

Breast Reconstruction

About DIEP Flap

Nowadays the most updated post – mastectomy procedures to replace a woman’s breast as naturally as possible, are based on “autologous free tissues transfer”. The “DIEP” flap is one of this technique; it consists in the use of an ellipse of fat and skin from the lower abdomen, below the umbilicus, as firstly described by the Japanese plastic surgeon Isao Koshima.

The name comes from the acronym of “Deep Inferior Epigastric Perforator”, which are the vessels that come from the deep inferior pelvis and “perforate” the muscle wall to vascularize the overlying fat tissue and skin.

These perforator vessels, approximately 1 mm large (up to 4 mm large in depth), are fundamental as they must be reconnected to the axillary vessels, to reestablish perfusion in the tissues transferred from the abdomen to the thoracic wall, as a natural part of the body.

The flap was then used in breast reconstruction for the first time in 1994 by Robert J. Allen, a plastic surgeon from United States. Before then a similar technique named “TRAM” (Transverse Rectus Abdominis Myocutaneous) was used, which included also the transfer of part of the abdominal rectus muscle, and requiring the use of a prosthetic mesh to avoid the risk of abdominal bulging or erniation. It is important to remark that the DIEP flap procedure not transferring Rectus Abdominis muscle and respecting its innervation, reduced the incidence of erniation, around 0,3% without the use of prosthetic mesh.

Finally, breast reconstruction with DIEP flap may end up, for many women, with a better appearance of the breast, looking younger, stiffer and higher.

Finally, breast reconstruction with DIEP flap may end up, for many women, with a better appearance of the breast, looking younger, stiffer and higher. It is true that is impossible to replace a breast gland with all its functions, but looking at today’s results, especially concerning consistency, heat, naturalness in shape and position, persistency of results, and extremely rare complications with no risk of capsule contracture, the DIEP flap procedure can be defined as an “Intervention for Restoration of the MAmmae” or with the acronym “IRMA”.

This explains the origin of the name Irma, given to the protagonist of the 3D Video showing the procedure on this web site, and then extended also to Prof. Santanelli di Pompeo di Pompeo’s equipe.

The Procedure

The procedure is usually performed simultaneously to the mastectomy. i.e. “immediate reconstruction”, thus avoiding the waiting term before reconstruction, which produces a relevant psychological distress to a woman, living for several months without the breast.

While the General Surgeon performs mastectomy and lymphnodes dissection according to needs, the Plastic Surgeons harvest an elliptic area of abdominal skin and fat tissue – not muscle – below the umbilicus. With the aid of magnifying loupes, together with abdominal tissues the tiny system of “perforator” vessels is dissected sparing the Rectus Abdominis muscle and preserving its motor innervation. This flap of skin and fat tissue is then positioned to replace the breast, connecting the harvested inferior deep epigastric vessels to the recipient vessels in the axilla (scapular circumflex vessels), or in the thoracic wall (internal mammary vessels), to reestablish normal perfusion and oxygenation to the reconstructed breast.

The skin and fat tissue flap fits aesthetically well into the new position due to the help of the natural roundness of the belly, hence replacing a breast as similar as possible to removed native one. Prof. Santanelli di Pompeo di Pompeo’s IRMA equipe usually performs this procedure in three hours and half. Sometimes the procedure needs to be completed with contralateral breast adjustment of shape and size. Thanks to these very short operative times, contralateral breast procedure can be performed at the same time, and whenever possible, the reconstruction of the Nipple-Areola complex is also performed with only a minimal extension of operative time (mean four hours and forty minutes). In this way, it is possible to achieve the goal of having the reconstruction track completed in a single stage. Otherwise it is possible to delay the contralateral balancing procedure and the Nipple-Areola complex reconstruction to a second stage, with a short operation.

In few selected cases, when the general surgeon can perform a “nipple sparing” mastectomy, saving the whole breast skin along with the nipple and areola complex, the plastic surgeon can achieve excellent results for breast shape and symmetry, with hidden scars, in a single stage. The decision on which type of mastectomy to be performed depends exclusively on the general surgeon and according to the patient’s clinical situation.

The lower abdominal wall, where the flap has been harvested, is then closed repositioning the umbilicus and leaving a nice flat abdomen. This step of the procedure is similar to an aesthetic “abdominoplasty” required by those who desire a reshaped belly, following a consistent weight loss that has caused tissues relaxation, or following pregnancies.

Results

The adipose tissue from the abdomen cannot replace the functions of the breast gland, but it is very similar to it in terms of consistency, temperature, behavior during movements, natural ptosis. The new breast will retain these aspects, and as the native one it will gain or lose weight, following a natural aging process along with the rest of the body. To note that skin texture of the breast and abdomen are often very similar. Minor shape irregularities or volume discrepancies between the two breasts might eventually be corrected later with fat injections, harvested in small amounts from different body areas, with the “lipofilling” technique.

Being an “autologous transplant”, the DIEP flap shows very low incidence of infections and no “capsule contraction” phenomenon, which usually affect foreign bodies such as breast implants, especially after radiotherapy. When performed after radiotherapy, the DIEP flap might improve local tissue condition due to its neovascular supply.

Following a “modified radical mastectomy” with breast skin resection, the new breast reconstructed with the DIEP flap recovers a poor superficial tactile sensibility, better if performed as an “immediate” procedure rather than “delayed”. Nevertheless, it does not compromise patient’s satisfaction for the reconstruction. When a skin and nipple preserving procedure, “nipple sparing”, is performed, a satisfactory sensibility of both components is obtained in due time.

Any surgical procedure ends up with one or more scars; following a radical procedure to resect an affected breast gland, a reconstruction with DIEP flap produces, on the breast mound around the transferred flap, an elliptic scar that might be thin but long as the required size of the resection.

In selected cases, whenever it has been possible to resect the gland sparing the skin and the Nipple-Areola complex, the flap can be inserted through an access along the inframammary crease, where a well-hidden scar will be located.

On the abdominal donor area, slightly above the pubis, will result a long horizontal scar going from one iliac spine to the other, and looking very similar to the one resulting after an aesthetic “abdominoplasty”; this scar can easily be covered by underwear or by the bikini.

Other Techniques

Other than the DIEP or SIAE flap, both harvested from the abdomen, the breast can be reconstructed with other tissues from the body, as those harvested from the inner thigh, TMG flap (Transverse Myocutaneous Gracilis), or from the upper buttock, SGAP flap (Superior Gluteal Artery Perforator), with similar procedures.

The execution of these procedures is more difficult and uncomfortable due to location of the donor area, with operative time lengthening; for this reasons Prof. Santanelli di Pompeo di Pompeo considers these flaps as second choice techniques.

Frequently Asked Questions

Q: Why have I never heard about breast reconstruction with the DIEP flap before?

A: In other European countries and North America the DIEP flap is often the first choice for breast reconstruction after radical mastectomy for breast cancer, while in Italy this procedure is not widely diffused because it requires a high-level, specialist surgical competence. The procedure is state-aided, yet not adequately refunded from the national health service, thus not all potential patients can benefit from DIEP flap.

Q: In which circumstances the DIEP flap procedure cannot be performed?

A: Sometimes when the abdomen presents scars and previous surgical procedures that interfered with vascularization; if it is not possible, or the patient is not willing, to undergo a surgical procedure that lasts more than 4 hours. If abdominal tissues are insufficient, even though today’s trend is to still perform a small DIEP flap that will be successively integrated with lipofilling.

Q: In case I underwent breast reconstruction with expander and prosthesis and the result does not satisfy me, or some complications or capsular contracture occurred, can I still benefit from DIEP flap?

A: Yes, if the basic conditions are met, a reconstruction with DIEP flap can be performed even after an unsatisfactory reconstruction with prosthesis, or after capsular contracture.

Q: Can the DIEP flap be performed to both breasts?

A: Yes. Prof. Santanelli di Pompeo has been the first in Italy to perform a bilateral DIEP flap in 2005, and until today he has performed several of these procedures in patients who underwent prophylactic mastectomy to the contralateral healthy breast.

Q: Can the DIEP flap procedure be repeated?

A: No, the harvest of abdominal tissues is possible only once.

Q: What is the operative time and which are the intraoperative risks?

A: The operative time depends on the experience of the team. We perform the operation in a single stage in 3 hours and 30 minutes, one more hour if comprising contralateral breast adjustment. In case of a bilateral procedure, the operative time is around 7 hours. Such a long anesthesia is not demanding on the body and, however, the patient is strictly monitored by the anesthesiologists, which are part and parcel of the IRMA Team.

Q: How will my belly be after the operation?

A: The belly will be flattened. During convalescence, you should wear an abdominal binder, day and night, for one month from operation. You will experience a sensation of tension to the abdomen that will gradually assuage week after week, until it vanishes. Sensibility of the suprapubic area will be slightly reduced, but it will improve. Instead, the “flattened belly” result remains unchanged.

Q: How will skin sensibility of the new breast be?

A: Sometimes quite reduced, mainly after delayed rconstructions. Nevertheless, this does not mean that you will not feel the entire organ. Sensibility is better when, according to the General Surgeon’s needs, the native breast skin can be preserved along with the nipple.

Q: Will I have to repeat the operation?

A: No. Since implants are not used, the reconstruction with autologous tissues does not require further operations. To enhance symmetry, it might be necessary to perform additional procedures, however they are only minor and less demanding operations.

Q: Which are the risks of complications and failure of this procedure?

A: The major risk for the success of this procedure concerns vascularization, and occurs when the new anastomosed vessels fail to oxygenate tissues, or part of them. It is an exiguous minority of cases, varying from 0,1% to 10%. In prof. Santanelli di Pompeo’s experience it happened in 0.4% of cases. Among other possible complications, the most common one is partial tissues necrosis (7% of cases in the IRMA Team experience), which is corrected by removing the small amount of skin and adipose tissue that did not survive after the operation, without any aesthetic drawback. For these vascular issues, it is important to be a non-smoker.

About DIEP Flap

Nowadays the most updated post – mastectomy procedures to replace a woman’s breast as naturally as possible, are based on “autologous free tissues transfer”. The “DIEP” flap is one of this technique; it consists in the use of an ellipse of fat and skin from the lower abdomen, below the umbilicus, as firstly described by the Japanese plastic surgeon Isao Koshima.

The name comes from the acronym of “Deep Inferior Epigastric Perforator”, which are the vessels that come from the deep inferior pelvis and “perforate” the muscle wall to vascularize the overlying fat tissue and skin.

These perforator vessels, approximately 1 mm large (up to 4 mm large in depth), are fundamental as they must be reconnected to the axillary vessels, to reestablish perfusion in the tissues transferred from the abdomen to the thoracic wall, as a natural part of the body.

The flap was then used in breast reconstruction for the first time in 1994 by Robert J. Allen, a plastic surgeon from United States. Before then a similar technique named “TRAM” (Transverse Rectus Abdominis Myocutaneous) was used, which included also the transfer of part of the abdominal rectus muscle, and requiring the use of a prosthetic mesh to avoid the risk of abdominal bulging or erniation. It is important to remark that the DIEP flap procedure not transferring Rectus Abdominis muscle and respecting its innervation, reduced the incidence of erniation, around 0,3% without the use of prosthetic mesh.

Finally, breast reconstruction with DIEP flap may end up, for many women, with a better appearance of the breast, looking younger, stiffer and higher.

Finally, breast reconstruction with DIEP flap may end up, for many women, with a better appearance of the breast, looking younger, stiffer and higher. It is true that is impossible to replace a breast gland with all its functions, but looking at today’s results, especially concerning consistency, heat, naturalness in shape and position, persistency of results, and extremely rare complications with no risk of capsule contracture, the DIEP flap procedure can be defined as an “Intervention for Restoration of the MAmmae” or with the acronym “IRMA”.

This explains the origin of the name Irma, given to the protagonist of the 3D Video showing the procedure on this web site, and then extended also to Prof. Santanelli di Pompeo di Pompeo’s equipe.

The Procedure

The procedure is usually performed simultaneously to the mastectomy. i.e. “immediate reconstruction”, thus avoiding the waiting term before reconstruction, which produces a relevant psychological distress to a woman, living for several months without the breast.

While the General Surgeon performs mastectomy and lymphnodes dissection according to needs, the Plastic Surgeons harvest an elliptic area of abdominal skin and fat tissue – not muscle – below the umbilicus. With the aid of magnifying loupes, together with abdominal tissues the tiny system of “perforator” vessels is dissected sparing the Rectus Abdominis muscle and preserving its motor innervation. This flap of skin and fat tissue is then positioned to replace the breast, connecting the harvested inferior deep epigastric vessels to the recipient vessels in the axilla (scapular circumflex vessels), or in the thoracic wall (internal mammary vessels), to reestablish normal perfusion and oxygenation to the reconstructed breast.

The skin and fat tissue flap fits aesthetically well into the new position due to the help of the natural roundness of the belly, hence replacing a breast as similar as possible to removed native one. Prof. Santanelli di Pompeo di Pompeo’s IRMA equipe usually performs this procedure in three hours and half. Sometimes the procedure needs to be completed with contralateral breast adjustment of shape and size. Thanks to these very short operative times, contralateral breast procedure can be performed at the same time, and whenever possible, the reconstruction of the Nipple-Areola complex is also performed with only a minimal extension of operative time (mean four hours and forty minutes). In this way, it is possible to achieve the goal of having the reconstruction track completed in a single stage. Otherwise it is possible to delay the contralateral balancing procedure and the Nipple-Areola complex reconstruction to a second stage, with a short operation.

In few selected cases, when the general surgeon can perform a “nipple sparing” mastectomy, saving the whole breast skin along with the nipple and areola complex, the plastic surgeon can achieve excellent results for breast shape and symmetry, with hidden scars, in a single stage. The decision on which type of mastectomy to be performed depends exclusively on the general surgeon and according to the patient’s clinical situation.

The lower abdominal wall, where the flap has been harvested, is then closed repositioning the umbilicus and leaving a nice flat abdomen. This step of the procedure is similar to an aesthetic “abdominoplasty” required by those who desire a reshaped belly, following a consistent weight loss that has caused tissues relaxation, or following pregnancies.

Results

The adipose tissue from the abdomen cannot replace the functions of the breast gland, but it is very similar to it in terms of consistency, temperature, behavior during movements, natural ptosis. The new breast will retain these aspects, and as the native one it will gain or lose weight, following a natural aging process along with the rest of the body. To note that skin texture of the breast and abdomen are often very similar. Minor shape irregularities or volume discrepancies between the two breasts might eventually be corrected later with fat injections, harvested in small amounts from different body areas, with the “lipofilling” technique.

Being an “autologous transplant”, the DIEP flap shows very low incidence of infections and no “capsule contraction” phenomenon, which usually affect foreign bodies such as breast implants, especially after radiotherapy. When performed after radiotherapy, the DIEP flap might improve local tissue condition due to its neovascular supply.

Following a “modified radical mastectomy” with breast skin resection, the new breast reconstructed with the DIEP flap recovers a poor superficial tactile sensibility, better if performed as an “immediate” procedure rather than “delayed”. Nevertheless, it does not compromise patient’s satisfaction for the reconstruction. When a skin and nipple preserving procedure, “nipple sparing”, is performed, a satisfactory sensibility of both components is obtained in due time.

Any surgical procedure ends up with one or more scars; following a radical procedure to resect an affected breast gland, a reconstruction with DIEP flap produces, on the breast mound around the transferred flap, an elliptic scar that might be thin but long as the required size of the resection.

In selected cases, whenever it has been possible to resect the gland sparing the skin and the Nipple-Areola complex, the flap can be inserted through an access along the inframammary crease, where a well-hidden scar will be located.

On the abdominal donor area, slightly above the pubis, will result a long horizontal scar going from one iliac spine to the other, and looking very similar to the one resulting after an aesthetic “abdominoplasty”; this scar can easily be covered by underwear or by the bikini.

Other Techniques

Other than the DIEP or SIAE flap, both harvested from the abdomen, the breast can be reconstructed with other tissues from the body, as those harvested from the inner thigh, TMG flap (Transverse Myocutaneous Gracilis), or from the upper buttock, SGAP flap (Superior Gluteal Artery Perforator), with similar procedures.

The execution of these procedures is more difficult and uncomfortable due to location of the donor area, with operative time lengthening; for this reasons Prof. Santanelli di Pompeo di Pompeo considers these flaps as second choice techniques.

Frequently Asked Questions

Q: Why have I never heard about breast reconstruction with the DIEP flap before?

A: In other European countries and North America the DIEP flap is often the first choice for breast reconstruction after radical mastectomy for breast cancer, while in Italy this procedure is not widely diffused because it requires a high-level, specialist surgical competence. The procedure is state-aided, yet not adequately refunded from the national health service, thus not all potential patients can benefit from DIEP flap.

Q: In which circumstances the DIEP flap procedure cannot be performed?

A: Sometimes when the abdomen presents scars and previous surgical procedures that interfered with vascularization; if it is not possible, or the patient is not willing, to undergo a surgical procedure that lasts more than 4 hours. If abdominal tissues are insufficient, even though today’s trend is to still perform a small DIEP flap that will be successively integrated with lipofilling.

Q: In case I underwent breast reconstruction with expander and prosthesis and the result does not satisfy me, or some complications or capsular contracture occurred, can I still benefit from DIEP flap?

A: Yes, if the basic conditions are met, a reconstruction with DIEP flap can be performed even after an unsatisfactory reconstruction with prosthesis, or after capsular contracture.

Q: Can the DIEP flap be performed to both breasts?

A: Yes. Prof. Santanelli di Pompeo has been the first in Italy to perform a bilateral DIEP flap in 2005, and until today he has performed several of these procedures in patients who underwent prophylactic mastectomy to the contralateral healthy breast.

Q: Can the DIEP flap procedure be repeated?

A: No, the harvest of abdominal tissues is possible only once.

Q: What is the operative time and which are the intraoperative risks?

A: The operative time depends on the experience of the team. We perform the operation in a single stage in 3 hours and 30 minutes, one more hour if comprising contralateral breast adjustment. In case of a bilateral procedure, the operative time is around 7 hours. Such a long anesthesia is not demanding on the body and, however, the patient is strictly monitored by the anesthesiologists, which are part and parcel of the IRMA Team.

Q: How will my belly be after the operation?

A: The belly will be flattened. During convalescence, you should wear an abdominal binder, day and night, for one month from operation. You will experience a sensation of tension to the abdomen that will gradually assuage week after week, until it vanishes. Sensibility of the suprapubic area will be slightly reduced, but it will improve. Instead, the “flattened belly” result remains unchanged.

Q: How will skin sensibility of the new breast be?

A: Sometimes quite reduced, mainly after delayed rconstructions. Nevertheless, this does not mean that you will not feel the entire organ. Sensibility is better when, according to the General Surgeon’s needs, the native breast skin can be preserved along with the nipple.

Q: Will I have to repeat the operation?

A: No. Since implants are not used, the reconstruction with autologous tissues does not require further operations. To enhance symmetry, it might be necessary to perform additional procedures, however they are only minor and less demanding operations.

Q: Which are the risks of complications and failure of this procedure?

A: The major risk for the success of this procedure concerns vascularization, and occurs when the new anastomosed vessels fail to oxygenate tissues, or part of them. It is an exiguous minority of cases, varying from 0,1% to 10%. In prof. Santanelli di Pompeo’s experience it happened in 0.4% of cases. Among other possible complications, the most common one is partial tissues necrosis (7% of cases in the IRMA Team experience), which is corrected by removing the small amount of skin and adipose tissue that did not survive after the operation, without any aesthetic drawback. For these vascular issues, it is important to be a non-smoker.

Copyright © 2021 Prof. Fabio Santanelli di Pompeo | Web Design & Maintenance – MarketLink

Copyright © 2021 Prof. Fabio Santanelli di Pompeo | Web Design & Maintenance – MarketLink

Healing is a process that can be considered complete when, finally, you might recognize yourself into your own body, despite unavoidable changes...

In the last decades Plastic Surgery, has become part of the oncologic treatment protocol, as the importance of the reconstructive stage following resection of a diseased body part has been universally recognized. Concerning breast tumor, most advanced hospitals set up a “Breast Unit”, multidisciplinary functional unit composed by different specialists who cooperate to offer to the patient the best opportunity available from medical science, to contrast tumor disease and return to normal life.

There are several breast reconstructive procedures, even though expander and prosthesis is the most known. This web-site is dedicated to women undergoing mastectomy and willing to know all reconstructive opportunities. Main goal is to present “autologous” procedures using live tissues from the patient itself as a sort of “auto-transplant”. Advances in vascular microsurgery and in peri-operative patient care have allowed for outstanding steps forward to restore the female body image.

Once all aspects have been taken into proper consideration, a woman should be assisted during choice with broad information, evaluating pro and cons among any surgical procedure, so she can decide what is best for her.