1. BREAST RECONSTRUCTION WITH DIEP
FLAP-SPECIAL CONSIDERATIONS
Stamatis Sapountzis M.D
Division of Plastic Surgery
China Medical University Hospital

2. Goals of Breast Reconstruction
 Provide permanent breast contour
 Make the breasts look balanced
 Avoid the need for external prosthesis
 Re-establish normalcy and confidence

3. Breast Reconstruction
 Implant Based
 Autologous Tissue
 Implant + Autologous Tissue

4. Breast Reconstruction
 Implant Based
 Autologous Tissue
 Implant + Autologous Tissue

5. History
Vincenz Czerny
Oncology, gynecology
In 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

6. Why Breast Reconstruction
with abdominal tissue became
popular?

7. June 2010
87 tissue expander/implant
116 latissimus Dorsi
119 pedicle TRAM
117 DIEP flap

8. Free DIEP > Free TRAM
(Plast. Reconstr. Surg. 124: 752, 2009
Donor Site Morbidity
DIEP patients has one-half the risk
of abdominal bulge or hernia

11. Plast. Reconstr. Surg. 125: 772, 2010.)
Each perforators was
injected with contrast and
the flaps were subjected to
dynamic computed
tomography scanning.
Three-dimensional and four-dimensional computed tomographic
angiography was utilized to reappraise the zones of vascularity.

12. Hartrampf Holm

13. Three-dimensional computed tomography
angiogram
Perfusion tends to stay in one hemi- The injected medial perforator was connected
abdomen. to the contralateral medial row perforator
through indirect linking vessels via the
subdermal plexus.

14. (Above) Lateral row perforator is injected. At least two sets of linking vessels need
to 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..

16. 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.

17. 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.

18. Intraoperatively angiography following administration of 5 mg of
indocyanine green in aperipheral intravenous catheter

19. Results
Comparison of perfusion: DIEP – MS TRAM –Pedicle TRAM
not a significant difference between
zones 2 and 3

20. (Plast. Reconstr. Surg. 128: 581e, 2011
There were 228 patients, with 120 medial (52.6
percent) and 108 lateral (47.4 percent) branch flaps

22. 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.

23. 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

24. 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

25. Computed tomographic scan of a perforator originating from the lateral
branch 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

26. 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

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

29. Subfascial DIEP Flap

30. Dissection of the lower abdomen skin Longitudinal incision to the anterior rectus
and fat flap from the underlying sheath approximately 0.5 cm medial to the
aponeurosis terminates when the lateral border
lateral border of anterior rectus sheath
is reached

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

32. Identification of the lateral row of Transverse incision of the aponeurosis
perforators of the deep inferior toward the perforator
epigastric artery (DIEA) in the
subaponeurotic layer.

33. Subaponeurotic blunt dissection of the The anterior rectus sheath has been
deep inferior epigastric artery perforators incised and raised exposing the
is performed perforators piercing the posterior surface
of the fascia

35. Advantages
 Save time: easy plane between fascia and
muscle
 Safe dissection: blunt dissection
 Easy to define the largest perforator

37. 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

38. 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

39. 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

40. 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.

42. What is the best way to
inset the flap?

43. Two-esthetic unit breast reconstruction. (A) Single-esthetic unit breast reconstruction.
The mastectomy scar is excised. (B) The DIEAP (A) The skin in between the mastectomy scar
flap is inset in the center of the breast mound and the new inframammary fold is de-
creating a breast consisting of two-esthetic epithelialized. (B) The DIEAP flap extends to
units: the native skin and the flap’s skin paddle. the inframammary fold, reconstructing the
entire breast

45. 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

47. Can we perform abdominal
flaps after liposuction or
with the existence of
vertical laparotomy scars?

48. 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.

49. •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.

50. (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

52. Plastic and Reconstructive Surgery • May 2012

53. Thank you