Questions To Ask Your DIEP Flap Surgeon

If you are considering DIEP flap breast reconstruction finding the right surgical team is key. Before choosing a DIEP flap surgeon be sure to ask the following questions:

1. Are you certified by the American Board of Plastic Surgery? Your surgeon should be a board certified plastic surgeon.
2. Do you have extensive experience with this type of surgery - How many have you performed? Preferably your surgeon will have performed over 100 DIEP flap procedures.
3. What's your success rate? Top specialist centers boast a success rate of at least 98%.
4. 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).
5. How often do you plan to perform a DIEP flap but end up changing the procedure to a free TRAM flap during the surgery? The "conversion rate" to a free TRAM flap should be low.
6. 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.
7. 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.
8. 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.
9. 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. Again, this can prevent a nasty financial surprise after your surgery.

Hope that helps!

Dr C

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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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Breast Reconstruction Surgery Options After Mastectomy

Every woman has a right to breast reconstruction surgery after breast cancer. This has been a federal mandate for some time and insurance companies have to pay for breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are many different options available.

"Immediate" breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient's breast skin, a shorter/less obvious mastectomy scar and waking up with the new breast already in place (and avoiding the experience of a flat chest). It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.



"Delayed" reconstruction generally takes place after the mastectomy has healed. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceeding with reconstruction to allow the soft tissues to recover completely from the radiotherapy.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later.

Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are tissue implants that provide support and increase the amount of padding over the implant.

Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.

The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients typically a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominus) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or “pooching”) of the abdomen and even a hernia. Up until a few years ago, this was the gold standard in breast reconstruction.



DIEP flap breast reconstruction has replaced the TRAM flap as today's gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.

Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.

Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced procedures routinely.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction including advanced techniques like the DIEP flap procedure. Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog, on Facebook and on Twitter!

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Breast Reconstruction With Tissue Much Safer Than Implants When Radiation Planned After Mastectomy

A study published in the November issue of the International Journal of Radiation Oncology*Biology*Physics examined the effect of radiation therapy on different methods of immediate breast reconstruction surgery. For breast cancer patients who receive radiation therapy after a mastectomy and immediate breast reconstruction, autologous tissue reconstruction (ie reconstruction using their own tissue) provides fewer long-term complications and superior cosmetic results than breast reconstruction with a tissue expander and subsequent breast implant.

Many women choose to undergo breast reconstruction surgery at the same time as their mastectomy procedure (under the same anesthetic). This avoids many of the psycho-social issues women face when dealing with a flat chest after mastectomy alone. However, frequently radiation can negatively affect the outcome of reconstruction and increase the risk of long-term complications.

Radiation therapy is increasingly becoming the standard of care for high-risk breast cancer patients after mastectomy in an attempt to decrease local cancer recurrence. However, this can cause a problem for both patients and their radiation oncologists.

Researchers at the Department of Radiation Oncology at Long Island Radiation Therapy in Garden City, N.Y., the Department of Surgery at Long Island Jewish Hospital in New Hyde Park, N.Y., the Department of Surgery at North Shore University Hospital in Manhasset, N.Y., and the Department of Surgery at Winthrop University Hospital in Mineola, N.Y., looked at whether the type of reconstruction performed in women receiving radiation after a mastectomy had an impact on their long-term outcomes.

Two general types of breast reconstruction are available for patients facing mastectomy for breast cancer: autologous tissue reconstruction utilizing the patient's own tissue (eg DIEP flap, GAP flap, TRAM flap, or latissimus flap) transferred to the chest to recreate the breast(s); and tissue expander/implant reconstruction which involves placement of an inflatable tissue expander (temporary saline implant) and exchange for a permanent implant (saline or silicone) at a separate procedure later on.

This study involved the largest reported series of patients who sequentially underwent mastectomy, immediate reconstruction and postmastectomy radiation therapy. Ninety-two patients were observed for a period of 38 months following breast reconstruction and radiation therapy.

Researchers found that autologous breast reconstruction is better tolerated by breast cancer patients because it is associated with fewer long-term complications and better cosmetic results than tissue expander/implant reconstruction.

None of the 23 patients reconstructed with their own tissue required further surgery while 33% of tissue expander/implant patients needed surgery to correct a problem with their reconstruction. Eighty-three percent of autologous reconstruction patients reported acceptable cosmetic results, as opposed to only 54% of implant patients.

"This study is useful for patients who are candidates for either [method of reconstruction] and are making a decision with regards to reconstruction technique," Jigna Jhaveri, M.D., lead author of the study and a radiation oncologist at Advanced Radiation Centers of New York in Hauppauge, N.Y., said. "Our study provides evidence that patients who undergo autologous tissue reconstruction and radiation therapy have fewer long term complications and better cosmetic outcomes than those who undergo tissue expander/implant reconstruction and radiation therapy."

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Here's my take....

While some plastic surgeons will disagree with this statement I strongly believe that breast implants and radiation therapy do not get along (at all). I feel the complication rate in implant-reconstructed women receiving radiation therapy is very high, particularly long-term. The handful of women that "do fine" in the short-term will very frequently end up with hard, uncomfortable breasts as the irradiated tissue firms-up over time and squeezes down on the implant. In my opinion the re-operation rate is too high for tissue expander/implant reconstruction to be offered as a routine option when radiation is on the table. This study confirms that breast reconstruction using the patient's own tissue is far safer than tissue expander/implant reconstruction in women facing radiation therapy after mastectomy.

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy, particularly advanced perforator flap techniques such as the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following The Breast Cancer Reconstruction Blog.

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