DIEP Breast Reconstruction
DIEP breast reconstruction is an advanced technique in autologous (own tissue) transfer. DIEP is a refined version of the TRAM flap, in that the DIEP utilizes only the blood vessels, fat and skin from the abdomen. Unlike the TRAM flap, DIEP preserves the rectus abdominus muscle(s) thus allowing for preservation of abdominal strength and integrity. Though DIEP can be performed many, many years post mastectomy, in many instances DIEP is performed immediately after mastectomy.
Skin-sparing mastectomies are now being performed by many doctors, instead of removal of the entire breast. In a skin-sparing mastectomy, the physician removes the breast tissue, leaving the outer breast skin "envelope" intact. The "envelope" is then filled with transferred tissue, which creates a breast that is very close to the original. Many women are not aware of skin-sparing mastectomies or of DIEP and their benefits. If your surgeon is not performing skin-sparing mastectomies, you may want to inquire as to why not. I believe so much in these surgeries and hope to get the word out so women will know that better, less invasive options are available to them, other than the TRAM and LAT flaps, or removal of their entire breast(s).
DIEP is the breast reconstruction of the future. It is fast becoming the gold standard breast reconstruction...thus this site is dedicated to it. I hope you will help to pass the word on to women in need of a mastectomy. When we are initially diagnosed, our minds are so full of fear and not knowing where to turn or what to do, that sometimes we do not have time to think or time to do research. We feel pressured to move fast and therefore may make snap decisions.
Great news for BRCA gene patients who are seeking DIEP. The newest procedure involved with the skin-sparing mastectomy, is nipple sparing. The breast envelope, to include the nipple is saved. This is called Nipple Sparing Mastectomy or NSM. This procedure goes even further to leave a DIEP patient with an even more beautiful, closer to natural looking breast. You will have your original breast envelope as well as your original nipple. There aren't that many skilled surgical teams who are performing this procedure, yet, but as with DIEP, which only had a handful of skilled surgeons not too long ago...this too will become a very popular and sought out procedure. There is nothing like advancement.
Further update on techniques...you may want to inquire as to if you are a candidate for the inframammary incision (under the fold) technique and inquire if your surgeon(s) can perform it, whereby the breast tissue is removed through the folds beneath the breast and the reconstruction is done from that point. It allows the scar to be in a non-visible area thus leaving you with an even more natural looking breast.
Some Plastic Surgeons may not inform women that DIEP reconstruction is an option. There is a bit of consensus that when this occurs, it is probably due to the fact that the Plastic Surgeon does not perform the procedure. A Plastic Surgeon may generally "push" the surgery he or she is most familiar with, which is understandable. DIEP may sometimes be "poo-pooed" by some Plastic Surgeons. This may occur in instances where the physician does not have experience or familiarity with the procedure. There are also Plastic Surgeons who will lay it all out and provide helpful information on all available options for reconstruction, whether they perform the procedure, or not.
With a TRAM reconstruction, there may be certain lifting restrictions for the rest of a woman's life, which may differ from one doctor's order to another. Your physician will be able to advised you on the number of pounds allowed. Once healed, lifting restrictions are generally not an issue with DIEP.
After TRAM reconstructions, some women end up having more surgery for hernia repairs. Know your options. Do a lot of research and compare the surgeries before you make a decision. Do not let your Plastic Surgeon talk you into a reconstruction you do not want, simply because it may be the reconstruction he or she is more familiar with.
DIEP breast reconstruction is more complex than the TRAM flap. It requires a Plastic Surgeon highly skilled in microsurgery. For that reason, there are not that many Plastic Surgeons within the country who perform this type of reconstruction, though they are growing in number. Do not have a fear of traveling to get to those highly skilled physicians. It is much easier than you think and well worth what you gain in return.
It is my understanding that women who have had C-sections can still be candidates for DIEP reconstruction, though some women have been told they are not. Being that no muscle is compromised with DIEP, there is generally no issue. An exception may be if a woman's abdomen is so scarred from previous abdominal surgeries, the doc may not want to utilize the tissue. There may also be issues with damage to the vessels from prior surgeries. In that instance, if there is enough fat on the buttocks, you may be able to have the GAP flap, which utilizes skin, fat and vessels from the upper buttocks or the TUG flap, where skin, fat and vessels are taken from the inner thigh or the hip flap. Again, no muscle is used.
Some physicians may state that he/she will not know if you are a candidate for DIEP, until you are in surgery and your vessels can be observed. It is my understanding that with exception, it is generally not necessary to see the vessels in order to make a decision as to if a patient is a candidate for DIEP, or not...the exception being if you have had prior abdominal surgeries, which may have damaged the vessels. If there has been no abdominal surgeries, where is the need to first see the vessels? My Plastic Surgeon, who does mainly DIEP, GAP and hip flap reconstructions, never once mentioned having to first see my vessels (once in surgery) to see if the vessels were adequate. He used portable dopplers to make the assessment, during my consult. I have read where some physicians use ultrasound to make the assessment, prior to surgery. I signed a contract to have DIEP and that is the surgery I woke up with. If you do not want a TRAM reconstruction, you may want to seek another opinion. Make sure that the surgery contract states only DIEP...not DIEP or TRAM.
Know this: The DIEP and TRAM flaps are basically the same surgeries. The DIEP is an upgraded modification of the TRAM. The difference is this:
1. With the Pedicle TRAM the entire rectus abdominus muscle is removed (one sided or two sided), remains connected to its blood source and is tunneled up to create the breast.
2. With free TRAM, a section of the muscle surrounding the vessel is cut free and reconnected to a new blood source in the breast.
3. With DIEP, no muscle is used. Only skin, fat and vessels are removed, thus the patient generally has an easier, quicker recovery, with less pain and potential for complications. The surgery may or may not take longer than TRAM. It depends on the skill of the physician(s) and whether they work solo or as a team.
The immediate difference in the free TRAM vs the DIEP is that with DIEP, the doc dissects/teases the vessels from the muscle, whereas with TRAM, the doc takes a section of muscle surrounding the vessel. DIEP (not the TRAM) requires the skill of a microsurgeon in removal and reconnection of the vessels, for if the vessel is damaged during the dissection, the entire surgery may be jeopardized. Some docs may not be comfortable in dissecting the vessels from the muscle and prefer to take a small bit of muscle around the vessel. Any removal of abdominal muscle constitutes a TRAM surgery. Some docs may not be quite comfortable performing DIEP with radiated vessels and may prefer to perform a pedicle TRAM. Pedicle TRAM, in my opinion, is a very outmoded, barbaric form of breast reconstruction. It is hard to believe that it is still being performed. If a doc offered me a Pedicle TRAM, today, I would run. I had 28 radiation treatments, with an additional 5 radiation boosts (33 rad sessions, total) and I did not have any problems having DIEP reconstruction, nor did my Plastic Surgeon feel that he had to see my vessels before he would know if he could perform the surgery, or not. I waited a period of 7 months after my last rad treatment to have DIEP reconstruction.
I read where one woman stated she was told that the doc always takes "just a little muscle" when he does DIEP. Guess what??? That is not a DIEP. It's a free TRAM. I had a contact from another woman who informed me that her physician called the surgery a "DIEP TRAM", and that is what he was going to perform on her. I thought that surely she must be mistaken...but she was not. Yes...she woke up with a TRAM reconstruction. There is no such thing as a DIEP TRAM. It is either a DIEP or it is a TRAM. If you have done your research, when you consult with your PS, you will be well informed.
When seeking a Plastic Surgeon to perform your DIEP surgery, it is imperative that you locate a physician, who has an excellent track record in performing the surgery. When in consultation, some areas you may want to explore with your physician are as follows. Note that this list is not all inclusive:
* How many DIEP's has the physician performed and how consistent (100-200+ would be a good base number, with numerous surgeries performed per week)
* What is the physician's failure rate for the surgery (0-1% would be ideal, though sometimes a little bit higher...but not much)
* Does he/she work with a surgical team, giving you the opportunity to have mastectomy with immediate reconstruction? Having a surgical team allows for minimal hours under anesthesia versus a possible extra 4 hours or more of anesthesia, that may be necessary when reconstruction is performed by one surgeon.
* How long does the physician take to perform the surgery (5-8 hours for a bilateral is what you want...3-5 hours for a unilateral). The more experienced the physician, the greater potential for shorter surgical time.
* Request to see before and after photos, both good and bad outcomes. If the physician refuses to show the bad photos, you may want to get a second opinion. Why would the physician not want to show all of the cards on the table? If there were no bad outcomes, thus no bad photos...all the better.
* Request a "non-discriminate" contact list so that you are able to contact any patient of your choosing, both good and bad experiences.
* Be sure to discuss with the Plastic Surgeon what complications could possibly occur and what they can do to remedy them.
* Discuss with your doc whether he/she will include the removal of your "dog ears" as part of the reconstruction process. It should be included. You did not go to him/her with dog ears. You should not be left with this deformity. For those who do not know, dog ears are the pointy ends of skin on each side of the waist/hip area that are left over when the abdomen is stitched closed. They are generally repaired at stage two. I have heard that some docs are not addressing them and I am not understanding why the repair is not included in the reconstruction process, being that the dog ears are a result of reconstructing the breast(s). If your doc does not include the corrective repair in the reconstruction process, you may want to select another physician who does.
* One important area you may want to address with the Plastic Surgeon is if he/she accepts your insurance and if so, how well he/she works with your insurance company. Some Plastic Surgeons will go out of their way to make sure that the patient pays the least out-of-pocket amount as is possible. Unfortunately, some may not. You will also want to know if the Plastic surgeon will accept what your insurance company pays, along with your co-pay, as payment in full, or if he/she will balance bill you. If the Plastic surgeon does not accept what your insurance pays, along with your copay, as payment in full, you could have the potential of owing a few to many thousand dollars, for the balance of your surgery fee. It is best to have all of these answers up front, instead being surprised, later. Know, up front, how much the surgeon is going to require you to pay.
It is my opinion that the reason why the reimbursement rates by some insurance companies may be low is because they may know so little about DIEP reconstruction. Some docs may refuse to be a part of the insurance network, due to low reimbursement rates. It happened to me. My docs bowed out of my insurance network, midway through my reconstruction stages because the insurance payments from that company, for me and others, were too low. From what I understand, the insurance companies generally cover the TRAM, though I am not sure why they would cover the TRAM and not DIEP. TRAM has more potential for complications, which would cost them even more money. You may want to do all that is possible to help the insurance company better understand the DIEP reconstruction. It is for the benefit of all women who desire to have a surgery that is dedicated to restoring the wholeness of her being, with the least complications possible.
It pays to be well researched and well informed in understanding the options and choosing the correct physician. It took me a while, but I got there. Sharing all of this with you is only to make you aware that DIEP is an option for breast reconstruction, in the event that you did not know, as well as to make the point that you need to carefully evaluate a physician and feel comfortable with him or her and their expertise. There are some really fine Plastic Surgeons out there, but you have to research and carefully evaluate to make the correct choice. Do not accept this info as fact. You need to do your own research so that you can come to your own conclusions, regarding which reconstruction is right for you. I know of quite a few excellent Plastic Surgeons, who do wonderful work, with DIEP. More are up and coming, quite steadily, as DIEP becomes more in demand. Just be diligent in being informed so that when you do evaluate a potential PS, you are informed enough to know if he or she is the correct one for you. I finally found a highly skilled, artistic PS team and my DIEP breasts are wonderful. I wish the same for you.
In my opinion, of all breast reconstruction surgeries available, DIEP generally has the least complications, least pain and is less invasive than TRAM or LAT flaps, when performed by Plastic Surgeons who are highly skilled in the procedure. My very best to you.
For those of you wanting to compare the different reconstructions available, I recommend the Breast Reconstruction Guidebook
Disclaimer: Information presented within the pages of this website is, for the most part, that of my opinion and for informational purposes only and not to be used in place of the advice of your medical provider. You are strongly encouraged to seek the advice of your medical provider and to conduct your own research on any topic of interest, for fact finding.
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