Overview
Definition:
Deep Inferior Epigastric Perforator (DIEP) flap is a type of autologous breast reconstruction that utilizes a portion of the patient's own abdominal tissue (skin, subcutaneous fat) to create a new breast mound, without removing the rectus abdominis muscle
This is achieved by meticulously dissecting and transferring perforating blood vessels from the deep inferior epigastric artery and vein to supply the flap.
Epidemiology:
Autologous breast reconstruction rates are increasing, with DIEP flap being a preferred method for many patients due to its muscle-sparing nature
It is indicated for patients undergoing mastectomy or revision of previous reconstructions
Patient selection is crucial, requiring adequate abdominal tissue and suitable vascular supply.
Clinical Significance:
DIEP flap reconstruction offers a more natural-looking and feeling breast compared to prosthetic implants, with long-term durability and reduced risk of implant-related complications
It preserves abdominal wall strength, avoiding the morbidity associated with traditional TRAM flap surgery
This technique is a cornerstone of modern breast reconstruction, demanding advanced microsurgical skills.
Indications
Primary Indications:
Post-mastectomy breast reconstruction
patients seeking natural breast appearance and feel
patients desiring to avoid prosthetic implants
patients with adequate abdominal donor tissue.
Contraindications:
Previous extensive abdominal surgery compromising vascular supply
significant abdominal wall weakness
uncontrolled comorbidities (e.g., uncontrolled diabetes, severe peripheral vascular disease)
smoking or unwillingness to quit
patient preference for other methods
inadequate abdominal tissue or perforator vessels.
Patient Selection:
Thorough assessment of abdominal tissue volume and vascular perforators via physical examination and imaging (e.g., CT angiography)
evaluation of patient's overall health and smoking status
psychological readiness for a complex, multi-stage procedure.
Procedure Steps
Preoperative Planning:
Detailed patient counseling
marking of flap boundaries and perforator vessels on the abdomen
preoperative imaging (CT angiography) to map perforator anatomy and select the optimal perforator(s)
NPO status and bowel preparation
antibiotic prophylaxis.
Flap Elevation:
Surgical team collaboration (plastic surgeon and microsurgeon)
abdominal incision mirroring abdominoplasty markings
meticulous dissection of subcutaneous fat and vessels, identifying and isolating the deep inferior epigastric perforator vessels
preservation of rectus abdominis muscle and its innervation
dissection of the flap containing skin, fat, and identified perforators.
Vascular Anastomosis:
Preparation of recipient vessels in the chest wall (internal mammary artery and vein are most common)
microscopic dissection and preparation of the harvested flap pedicle
connection of the flap's arterial perforator to the recipient artery and the flap's venous perforator to the recipient vein using microsurgical techniques
confirmation of flap viability through Doppler assessment.
Flap Shaping And Closure:
Molding and shaping the flap to create the breast mound
securing the flap in position
closure of the abdominal wall defect, often with mesh reinforcement if needed
placement of drains
dressing application.
Postoperative Care
Monitoring Of Flap Viability:
Frequent clinical assessment (color, capillary refill, turgor) and Doppler monitoring of blood flow in the flap
vigilant observation for signs of vascular compromise (e.g., venous congestion, arterial occlusion)
immediate reporting of any concerns to the surgical team.
Pain Management And Mobilization:
Adequate analgesia
early ambulation as tolerated
avoidance of strenuous abdominal activity
gradual return to normal activities
management of surgical site pain.
Wound Care And Drain Management:
Regular wound inspection and dressing changes
monitoring of drain output and timely removal
management of any surgical site infections.
Comprehensive Patient Education:
Instructions on flap care, activity restrictions, signs of complications to watch for, and follow-up appointments
education on long-term breast self-examination.
Complications
Early Complications:
Flap failure (arterial occlusion or venous congestion)
partial flap necrosis
hematoma or seroma formation
wound dehiscence
infection
donor site morbidity (abdominal wall weakness, hernias, contour deformities).
Late Complications:
Fat necrosis within the flap
capsular contracture (if combined with implant)
asymmetry
sensation changes
contour irregularities
abdominal bulge or hernia recurrence.
Prevention Strategies:
Meticulous surgical technique, especially in microsurgical anastomosis
thorough preoperative assessment and imaging
careful patient selection and risk factor management (e.g., smoking cessation)
diligent postoperative monitoring
appropriate closure techniques for the abdominal wall.
Key Points
Exam Focus:
Understanding the DIEP flap as a muscle-sparing autologous reconstruction
differentiating it from TRAM flaps
knowing the key steps of flap elevation and anastomosis
recognizing common complications and their management
understanding the importance of perforator vessel identification.
Clinical Pearls:
CT angiography is critical for preoperative planning
the internal mammary vessels are the most common recipient vessels
meticulous microsurgical technique is paramount for flap survival
vigilant postoperative monitoring is non-negotiable
patient education on activity restrictions is vital.
Common Mistakes:
Inadequate perforator selection leading to flap failure
insufficient dissection of vessels causing tension on the anastomosis
neglecting to address abdominal wall integrity during closure
delaying intervention for signs of flap compromise
failing to counsel patients adequately on long-term expectations and risks.