BREAST RECONSTRUCTION WITH DIEP FLAP-SPECIAL CONSIDERATIONS

Stamatis Sapountzis M.D

Division of Plastic SurgeryChina Medical University Hospital

Goals of Breast Reconstruction

Provide permanent breast contour

Make the breasts look balanced

Avoid the need for external prosthesis

Re-establish normalcy and confidence

Breast Reconstruction

Implant Based Autologous Tissue Implant + Autologous Tissue

Breast Reconstruction

Implant Based Autologous Tissue Implant + Autologous Tissue

HistoryVincenz Czerny

Oncology, gynecologyIn 1895 he published the first account of a breast implant which he had carried out, by transferring a benign lipoma to "avoid asymmetry" after removing a tumor in a patient's breast.1879 performed the first total hysterectomy via the vagina

Why Breast Reconstruction with abdominal tissue

became popular?

June 2010

87 tissue expander/implant

116 latissimus Dorsi 119 pedicle TRAM

117 DIEP flap

Free DIEP > Free TRAM

(Plast. Reconstr. Surg. 124: 752, 2009

DIEP patients has one-half the risk of abdominal bulge

or hernia

Donor Site Morbidity

DIEP

FLap

Dissection

Aesthetic result

Perforator

selection

DIEP

FLap

Dissection

Aesthetic result

Perforator

selection

Three-dimensional and four-dimensional computed tomographic angiography was utilized to reappraise the zones of vascularity.

Plast. Reconstr. Surg. 125: 772, 2010.)

Each perforators was injected with contrast and the flaps were subjected to dynamic computed tomography scanning.

• 14 Lateral row

• 22 Medial Row

36 DIEP

FLAPS

HolmHartrampf

Three-dimensional computed tomography angiogram

Perfusion tends to stay in one hemi-abdomen.

The injected medial perforator was connected to the contralateral medial row perforator through indirect linking vessels via the subdermal plexus.

(Above) Lateral row perforator is injected. At least two sets of linking vessels needto be crossed to reach the midline

(Below) Medial row perforator is injected. Fewer linking vessels are required to cross the midline,thus contrast flows into zone II more easily, hence a more centralized perfusion..

Illustration of a medial perforator DIEP flap, in which perfusion is more centralized and has a bigger vascular territory. These are useful for large breast reconstructions.

Medial perforator DIEP flaps follow Hartrampf zones of perfusion. Zone II is on the contralateral hemi-abdomen.

Illustration of a lateral perforator DIEP flap, in which perfusion is more lateralized. These are useful for small to moderate sized and bilateral breast reconstructions.

Lateral perforator DIEP flaps follow Holm’s zones of perfusion.Zone II is on the ipsilateral hemi-abdomen.

Intraoperatively angiography following administration of 5 mg of indocyanine green in aperipheral

intravenous catheter

ResultsComparison of perfusion: DIEP – MS TRAM –Pedicle TRAM

not a significant difference betweenzones 2 and 3

(Plast. Reconstr. Surg. 128: 581e, 2011

There were 228 patients, with 120 medial (52.6 percent) and 108 lateral (47.4

percent) branch flaps

Regardless of whether the dominant perforator is laterally

or medially located, as long as it is included, a safe flap can be harvested and the perfusion related

complications can be reduced to an absolute minimum.

3 Key Points

1. Vessel diameter is important and Poiseuille’s law is determining.

The flow through a tube is related to the fourth power of the radius of a vessel

The flow in a vessel with a 2-

mm diameter is approximately 16 times higher than in a vessel with a diameter of 1 mm

3 Key Points

1. Vessel diameter is important and Poiseuille’s law is determining

2. The central positioning of the perforator in the flap is essential

3. The number and three-dimensional structure of the branches of the perforator, once it has pierced the deep fascia, will determine which areas of the flap will be vascularized

Computed tomographic scan of a perforator originating from the lateralbranch of the right deep inferior epigastric artery with a perforator that bends off laterally and vascularizes only the most lateral and ipsilateral part of the flap.

The Perfusion of the conventionally designed flap will be extremely poor

Multi-detector CT angiography scan Info on perforator location, diameter (>0.3mm, >1mm

included), intramuscular course, high spatial resolution allows multi-planar evaluation (3D view), less habitus dependent, predictive value on outcome (DIEP Vs MS free TRAM), can evaluate SIEA system

Reduced operative time. Sensitivity 99.6% (Rozen et al.)

Op time reduction average 100min (Casey et al, Smit et al, Masia et al)

Expensive Radiation dose Contrast

(Plast. Reconstr. Surg. 119: 18, 2007

DIEP

FLap

Dissection

Aesthetic result

Perforator

selection

Subfascial DIEP Flap

Dissection of the lower abdomen skin and fat flap from the underlying aponeurosis terminates when the lateral border of anterior rectus sheath is reached

Longitudinal incision to the anterior rectus sheath approximately 0.5 cm medial to the lateral border

The semilunar incision line (dotted line) through the anterior rectus sheath that is lateral to the lateral row of perforators

Identification of the lateral row of perforators of the deep inferior epigastric artery (DIEA) in the subaponeurotic layer.

Transverse incision of the aponeurosis toward the perforator

The anterior rectus sheath has been incised and raised exposing the perforators piercing the posterior surface of the fascia

Subaponeurotic blunt dissection of the deep inferior epigastric artery perforators is performed

Advantages

Save time: easy plane between fascia and muscle

Safe dissection: blunt dissection

Easy to define the largest perforator

DIEP

FLap

Dissection

Aesthetic result

Perforator

selection

Raising a flap with a skin paddle with less vertical height reduces the donor site morbidity, especially in terms of reducing the risk of wound dehiscence,as tight abdominal closure is avoided (e.g in thin patients)The technique we describe offers the patient a naturally shaped breast that can be achieved without the need to raise a very large abdominal flap

Projection the mastectomy scar onto the contralateral breast and measurement of the dimensions of skin in the area of the breast inferior to this imaginary scar line

An inverted V-shaped flap is designed on the inferior mastectomy skin flap and a template of this also made

This triangular template is then superimposed on the inferior aspect of the template and excised because this part of the skin in the new breast will be created by the mastectomy skin flap

When the breast template is opened and flattened the shape of the required flap is almost rectangular.

The V shaped scar is on the underside of the breast occupying a natural aesthetic subunit of the breast, thus making it inconspicuous.

A fatty layer is also included from the upper abdominoplasty flap to partially fill the upper poles of the new breast.

What is the best way to inset the flap?

Two-esthetic unit breast reconstruction. (A) The mastectomy scar is excised. (B) The DIEAP flap is inset in the center of the breast mound creating a breast consisting of two-esthetic units: the native skin and the flap’s skin paddle.

Single-esthetic unit breast reconstruction. (A) The skin in between the mastectomy scar and the new inframammary fold is de-epithelialized. (B) The DIEAP flap extends to the inframammary fold, reconstructing the entire breast

A skin envelope is created with tissue expander and then the expander is replaced with a de-epithelialised flap, leaves a breast with the original mastectomy scar and no skin island

Can we perform abdominal flaps after liposuction or with the existence of

vertical laparotomy scars?

8 cases (7 autologous breast reconstruction, 1 thigh reconstruction. All patients had a vertical abdominal midline scar as a result of a previous surgical intervention.

•In the past was contraindication

•Preoperative colour duplex or CT angiography is mandatory

•The dissection of the perforator flaps was sometimes more difficult due to increased fibrosis and scar formation of the subcutaneous tissue.

(Ann Plast Surg 2011;67: 251–254)

11 DIEPS contained a midline scar

In flaps with a midline scar approximately 70% of the entire flap volume appeared to be well vascularized (pink area) after harvest

Plastic and Reconstructive Surgery • May 2012

Thank you