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Are All DIEP Flaps the Same?

Are All DIEP Flaps the Same?
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Published on March 30, 2020

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This content provided by our partner:  DiepCFoundation.org

It is a fair question to ask don’t you think?  It is even a better question to discuss at your initial consult when you want to use your tummy tissue to reconstruct your breasts. If you have been affected by breast cancer and are facing a mastectomy, I think you should ask your plastic surgeon, “Are all DIEP flaps the same?

The video embedded in the blog will give you talking points to have the discussion with your plastic surgeon. I was fortunate to interview Drs. Pankaj Tiwari and Ergun Kocak of Midwest Breast in Ohio to help the reader understand the nuances and differences in tummy flap breast reconstruction.

What are the Differences in Flap Procedures Using the Tummy?

These surgeons point out the scar on the outside looks similar to a tummy tuck scar. But what happens on the inside as Dr. Kocak says, “it’s entirely different”. Let’s take a look “under the hood” for abdominal based flap procedures. It’s all about how much muscle is or is not taken during breast reconstruction surgery.

Pedicle TRAM vs. DIEP Flap Breast Reconstruction

Dr. Tiwari explains a pedicle TRAM is when one of the six pack muscles is used. He states you have a “3-pack and a 3-pack”.  One set of the six pack muscles in the abdominal area is tunneled through the chest and rotated up to the breast area. This type of reconstruction goes through a real anatomical structure called the inframammary fold. Once this has been disrupted, it leaves the tissue “almost sliding down the chest”. This type of reconstruction, because it is the least robust, less dominant blood supply to the tissue, there have been issues with more fat necrosis, skin dying.

It is not a microsurgical free flap like a DIEP flap, free TRAM or a muscle sparing TRAM. It can be very limiting for patients in terms of movements like getting out of a chair or bed because you have lost core stability.

Free TRAM vs. DIEP Flap Breast Reconstruction

The free TRAM still takes the entire six pack muscle. The difference between this and the TRAM instead of being tunneled and rotated up, it is now detached completely and transplanted not based on the vessels coming from the top, the superior vessels, but the vessels coming from the bottom, the inferior vessels. Dr. Kocak points out, “Ironically, those inferior vessels are way superior. Thus, less fat necrosis presents itself during a free TRAM. This flap was based on the dominant blood supply.

Dr. Tiwari points out because it is a free flap you have 3-dimensional, rotational freedom to create a better-looking breast and there was no more tunneling. Dr. Kocak shares an important fact that many of these closures in the abdominal area required mesh. This is because the six-pack muscle was still used and the fascia (connective tissue) was taken.

DIEP Flap Breast Reconstruction

As plastic surgery evolved and understanding more how the skin and fat got its blood supply, surgeons learned it was not the muscle but blood vessels perforating through the muscles where the blood source is. Now they are doing perforators flaps which is what a DIEP flap is, deep inferior epigastric perforators. The muscle, in most instances is spared because the vessels are teased out of the muscle through microsurgical skill using high powered microscopes. Not only are they preserving the muscle, but also the nerves, therefore avoiding the incidence of hernias and bulging.

Drs. Kocak and Tiwari snap a photo of the back of the flap intraoperatively for the patient’s record. If there is any abdominal pain or weakness, this allows the surgeon to speak to the patient and help them understand the surgical procedure performed on them.

Drs. Kocak and Tiwari snap a photo of the back of the flap intraoperatively for the patient’s record. If there is any abdominal pain or weakness, this allows the surgeon to speak to the patient and help them understand the surgical procedure performed on them.

Many thanks to Drs. Pankaj Tiwari and Ergun Kocak for their time and expertise.

Disclaimer

References made to my surgical group, surgeon and healthcare team are made because they are aligned with my values and met my criterion after I did research of their practices and success rates. Any other healthcare provider that displays the same skill, compassion education and outreach to patients will be given consideration and recognition on this website.  The information contained on this website is not a substitute for or should be construed as medical advice. Please consult a licensed physician for medical advice.
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