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 With Tummy Tissue (Abdominal Flaps)

DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it's difficult to understand what these terms really mean and what the differences are between all these "tummy flap" procedures.

It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.

Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient's own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: a TRAM flap, DIEP flap, or SIEA flap.

The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap ("pedicle", "free", and "muscle-sparing free"): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20% or more), bulging (or "pooching"), and even abdominal hernia.

The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The “SIEA” blood vessels are generally found in the fatty tissue just below skin whereas the “DIEP” blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging). Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery.

Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20% of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.

Since the TRAM, DIEP and SIEA procedures all use the patient's lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.

There are many plastic surgeons in the US offering TRAM flap reconstruction. Unfortunately, very few centers in the US routinely perform the advanced microsurgical procedures like the DIEP and SIEA flap. Many patients will therefore have to travel for these procedures.

When considering a reconstructive surgeon, ensure he/she is a plastic surgeon certified by the American Board of Plastic Surgery that has extensive experience with this specific type of surgery. Also ask about the success rate in their hands - most specialists boast a flap survival rate of 97% to 99%+.

The 2 websites below list surgeons that offer DIEP and SIEA flap reconstruction and serve as a good starting point when researching surgeons:

www.diepbreastreconstruction.org and www.breastrecon.com

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Dr Chrysopoulo is a board certified plastic surgeon at PRMA Plastic Surgery. PRMA specializes in microsurgical breast reconstruction including the DIEP flap procedure. PRMA has performed over 3,250 DIEP flaps and is In-Network for most US insurance plans. On Facebook?.... Connect with other breast cancer patients in our FB Breast Cancer Reconstruction Community.

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TRAM Flap vs DIEP Flap: What's the Difference?

Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient's researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today's cutting edge DIEP procedure.

There are three main forms of the TRAM flap operation commonly performed by plastic surgeons:

1) The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, the lower abdominal tissue below the belly button (skin, fat and one of the abdominal muscles) is tunneled under the upper abdominal skin to the chest to create a new breast.

Recovery from the surgery can be difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%). As with any surgical procedure there is the possibility of complications. These include delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), abdominal complications such as bulging and/or hernia, and loss of the reconstruction altogether (rare).

2) The Free TRAM flap: this procedure uses the same abdominal tissue as the pedicled TRAM except that the tissue ("flap") is disconnected from the patient's body, transplanted to the chest, and reconnected to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower).

Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling).

3) The Muscle-Sparing Free TRAM flap: this operation is associated with all the benefits of the free TRAM but has significantly fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very small (postage-stamp size). We will opt for this version of the TRAM only in the rare event that the patient's anatomy does not allow for a DIEP or SIEA flap.

4) The DIEP flap: This is the most advanced form of breast reconstruction surgery available today. Like the muscle-sparing free TRAM, the DIEP uses the patient's own abdominal skin and fat to reconstruct a natural, soft breast after mastectomy. Unlike the TRAM however, all the abdominal muscle is preserved. Only abdominal skin and fat are removed similar to a "tummy tuck". Patients therefore experience less pain after surgery, enjoy a faster recovery and maintain their abdominal strength long-term. Since the abdominal muscles are saved, the risk of complications like abdominal bulging and hernia are also significantly lower. Please visit our gallery to view DIEP flap before and after photos.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques including DIEP flap surgery. He and his partners perform over 500 DIEP flap procedures per year and are In-Network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

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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 Surgery - Part III - Perforator Flap Reconstruction

The ideal breast reconstruction technique is one which allows reconstruction of a “natural”, warm, soft breast with the least impact on the patient’s body. While breast reconstruction with stem cells may not be too far off, until it becomes a reality we are limited to using the patient’s own tissue to achieve these goals. As discussed in the previous posts in this breast reconstruction series, until fairly recently the only “tissue reconstruction” options involved sacrificing muscle. This made recovery from the surgery difficult and painful, not to mention the risk of long-term muscle function loss and weakness.

Perforator flap techniques use skin and fat from various parts of the body. All muscles are preserved. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. The downside to these procedures is that they are technically much more demanding than other breast reconstruction techniques and require microsurgical expertise. For this reason they are not offered by many plastic surgeons and patients must be prepared to travel when choosing these procedures.

DIEP (Deep Inferior Epigastric Perforator) Flap

The DIEP flap is the latest evolution of the TRAM flap (discussed in Part II) and represents today's gold standard in breast reconstruction. The DIEP flap procedure is similar to the TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to dissect the vessels and microsurgery is required to reattach the blood vessels to the chest area.

Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP flap procedure. As a result, patients do not have to sacrifice their abdominal strength and they experience less pain and a much quicker recovery. The risk of abdominal bulging and hernia is also very small.

The DIEP flap was first described in the early 1990's but has remained much less popular than the TRAM flap among plastic surgeons, presumably because of the increased complexity and difficulty of the procedure compared to the TRAM.

So the advantages of the DIEP flap are multiple: it uses living tissue to recreate a breast that often looks and feels like a normal breast; abdominal strength is not affected; the risk of bulging or hernias is significantly reduced; and, like the TRAM flap, the patient benefits from a simultaneous “tummy-tuck”.

The DIEP flap is a very technically demanding operation but the benefits are tremendous for the patient, especially when performed at the same time as a skin-sparing mastectomy.

SIEA (Superficial Inferior Epigastric Artery) Flap

The SIEA flap procedure is very similar to the DIEP flap procedure. The main difference between the SIEA and DIEP is the artery used for blood flow supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin.

As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient's skin and fat to reconstruct the breast. While the SIEA flap procedure is similar to the DIEP it is used less frequently since less than 20% of patients have the anatomy required to allow this procedure.

GAP (Gluteal Artery Perforator) Flap

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP flap. This procedure uses excess skin and fat from the gluteal or buttock region. Fat and skin from either the upper or lower buttock region can be used and microsurgically transplanted to the chest.

Once again, no muscle is sacrificed. Incisions can generally be hidden by most underwear. If a patient requires a bilateral reconstruction with GAP flaps most surgeons prefer to only perform one side at a time. It is important to discuss this possibility with your surgeon.

Advantages of the GAP flap include: a scar that is generally hidden with underwear or swimsuits, and no loss of muscle function or strength.

Other Breast Reconstruction Options:

TUG (Transverse Upper Gracilis) Flap

Like the GAP flap, the TUG flap is an option in cases where there is not enough lower abdominal tissue to reconstruct the breast(s). The TUG procedure uses the upper part of the inner thigh; skin, fat and a small amount of muscle are disconnected and transferred to the chest to create the new breast. The patient benefits from a simultaneous inner thigh lift. Once again, this procedure is not widely available due to its complexity and need for microsurgical expertise.

It is important to realize that whichever method of reconstruction is used, the vast majority of women will require 2 or even 3 procedures for the optimal cosmetic result. Each procedure is typically separated by several weeks. The entire reconstructive process, regardless of the method of reconstruction, can therefore take several months to complete. However, breast reconstruction does NOT typically complicate or delay cancer treatment such as chemotherapy.

With all this in mind and also remembering the superior cosmetic results associated with immediate breast reconstruction (reconstruction performed at the same time as mastectomy), it is recommended that women discuss their reconstructive options with a plastic surgeon specializing in breast reconstruction before undergoing mastectomy whenever possible.

For more information about breast reconstruction options please visit www.prma-Enhance.com. For the latest news and developments in breast reconstruction please also visit The Breast Cancer Reconstruction Blog.

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Dr Chrysopoulo, board certified plastic surgeon, PRMA Plastic Surgery, San Antonio, TX. Specializing in breast reconstruction surgery after mastectomy for breast cancer. Over 350 DIEP flaps performed yearly. In-network for most US insurance plans. Toll Free (800) 692-5565. www.prma-Enhance.com. Latest breast reconstruction news available at The Breast Cancer Reconstruction Blog.

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Comparison of Abdominal Donor-Site Morbidity of SIEA, DIEP, and Muscle-Sparing Free TRAM Flaps for Breast Reconstruction.

A study published in September's edition of Plastic and Reconstructive Surgery examined the abdominal recovery rates and patient satisfaction after breast reconstruction with different abdominal flaps: the DIEP, SIEA and muscle-sparing free TRAM. The SIEA (superficial inferior epigastric artery) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published reports comparing the donor-site morbidity of SIEA flaps to that of TRAM (transverse rectus abdominis myocutaneous) flaps or DIEP (deep inferior epigastric artery perforator) flaps. A description of how these abdominal flap breast reconstruction procedures differ is available here.

The authors of the study used a 12-question patient survey and retrospective chart review to compare donor-site (abdominal) function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period.

Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting ability. Abdominal pain also seemed to lessen sooner in the unilateral SIEA group (though this was not statistically significant) when compared to the muscle-sparing free TRAM group. Bilateral breast reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps. The greatest benefit of the SIEA flap occurs in cases of bilateral breast reconstruction where at least one of the flaps used is an SIEA flap. There were no differences between patients that had undergone reconstruction of only 1 breast (unilateral) with an SIEA flap versus those that had had a DIEP flap.

The authors' conclusions were that breast reconstruction using SIEA flaps results in significantly less abdominal donor-site issues than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in both unilateral and bilateral cases. The authors felt that these differences were "clinically relevant" and recommended that SIEA flaps be used whenever possible in preference to DIEP or muscle-sparing free TRAM flaps for breast reconstruction.

These findings are not surprising to me at all. They make a lot of sense considering that the SIEA flap procedure requires the least amount of surgical dissection while the muscle-sparing free TRAM is the most invasive (due to removal of some of the rectus abdominis muscle). One would expect recovery to be easiest in patients that undergo the least invasive surgery and this is essentially what this study has shown. Interestingly though, in patients undergoing unilateral breast reconstruction (one breast only), DIEP flaps are just as good as SIEA flaps in terms of recovery and patient satisfaction even though the DIEP procedure is slightly more invasive.

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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including 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 Dr Chrysopoulo's Breast Cancer Reconstruction Blog.

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Microsurgical Breast Reconstruction With Perforator Flaps

So what are "perforator flaps"?

Pioneered in the early 1990's, perforator flap breast reconstruction represents the state of the art in breast reconstruction surgery after mastectomy. The tissue removed at the time of mastectomy may be replaced with the patient's own warm, soft, living tissue to recreate a "natural" breast.

Skin, fatty tissue, and the tiny blood vessels that supply nutrients to the tissue ("perforators") can be taken from the patient's abdomen (SIEA flap and DIEP flap procedures) or buttocks (GAP flap procedure).

Unlike conventional tissue reconstruction techniques (like the TRAM flap), these microsurgical perforator flap techniques carefully preserve the patient's underlying musculature. The tissue is then transplanted to the patient's chest and reconnected using microsurgery.

Preserving underlying muscles lessens postoperative discomfort making the recovery easier and shorter, and also enables the patient to maintain muscle strength long-term. This is particularly important for active women.

While microsurgical breast reconstruction offers many advantages to the patient, the surgeries are very complex and time-consuming and specialized training is required. Our surgeons perform over 300 microsurgical breast procedures per year making PRMA Plastic Surgery one of the busiest breast reconstruction centers in and beyond the USA.

To learn more about each of the perforator flap techniques offered at PRMA please click on the following links:

DIEP flap
SIEA flap
GAP flap

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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