Breast Reconstruction – PERFORATOR FLAPS – DIEP SIEA with Dr. Kind
An exciting development in microsurgical reconstruction is the increasing use of perforator flaps. These flaps preserve the underlying muscle by dissecting the blood vessels through or around the muscle. Theoretically any muscle flap that includes a paddle of skin can be harvested as a perforator flap. In practice there are several perforator flaps which have been used for various reconstructive needs around the body. A few of these include the lateral arm, the anterolateral thigh, and the thoracodorsal artery perforator flaps. These flaps generally provide good thin soft tissue coverage, and since they do not include muscle, the donor defect created results in minimal deformity and less pain than a muscle flap.
In the mid-1990′s it was recognized that the TRAM flap could be harvested without the rectus abdominis muscle by dissecting the blood vessels (the perforating vessels to the skin and fat) through the muscle (see figure 2). This flap, called the deep inferior epigastric perforator or DIEP flap (see figure 3), uses the same skin and fat of the lower abdomen as the TRAM to reconstruct a breast. There are several published series in the medical literature that show that patients who undergo this procedure have less pain and a faster recovery than patients who undergo TRAM flap reconstruction. There is also less risk of abdominal wall weakness and herniation. Finally, since the flap is taken from the low abdomen like a TRAM flap, there is the added benefit of a "tummy-tuck", with the abdomen nicely re-contoured.
Figure 2
Figure 3
The DIEP harvest is longer and more complicated than a TRAM flap, but for most patients this is more than offset by the benefits to the abdominal wall.
In approximately 15% of patients, there are no large perforators coming through the muscle. In these patients the skin and fat of the lower abdomen are supplied by a more superficial blood vessel, the superficial inferior epigastric artery. This blood vessel is a branch of the femoral artery, and courses through the tissues of the lower abdomen without going through the rectus abdominis muscle. In these patients breast reconstruction can be performed with a flap of fat and skin from the lower abdomen without having to dissect through the rectus abdominis muscle. This flap is called the superficial inferior epigastric artery or SIEA flap.
Each time that Dr. Kind dissects a DIEP flap, he carefully looks for and preserves the superficial inferior epigastric blood vessels. If these vessels are of sufficient size, the SIEA flap can be used.
Figure 4 – Left breast reconstruction with DIEP flap.
Note the intact rectus abdominis muscle. This plastic surgeon in San Francisco serving the Bay Area offers all aspects of plastic surgery including tummy tucks, facelifts, nose surgery, breast reduction and more. Contact Dr Kind at 415-565-6884 or email us. View plastic surgery photos from this San Francisco plastic surgeon.