DIEP FLAP
Breast reconstruction: Breast construction with DIEP Flap (Deep Inferior Epigastric Artery Perforator Flap)
Flap transplants in which the intramuscular vessels are dissected are referred to as perforator flaps. The DIEP flap has proved to be a beneficial procedure in autologous breast reconstruction in many ways. The indication for a DIEP is the same as for the free TRAM flap.
The deep inferior epigastric artery perforator flap (DIEP) was first described by Koshima in 1989. In 1994 this procedure was adopted by Allen for autologous breast reconstruction. The tissue block has the same dimensions as the TRAM flap, but in contrast is supplied by only one, two or three perforator vessels originating from the deep inferior epigastric artery system. This transplantation therefore has the advantages of the free TRAM flap, such as large volume and good modelling characteristics without the need to sacrifice either fascia or musculature.
As no musculofascial defect is caused and segmental innervation of the rectus abdominis muscle as well as muscular integrity can be maintained, donor site morbidity in the hypogastrium could be significantly reduced with this transplant procedure.
The procedure for flap dissection follows the same methods as in free TRAM. The transplant is dissected epifascially until a strong perforator artery perforates the fascia. After incision of the fascia, the rectus musculature is spread out and the perforator vessels followed via the inferior epigastric vessels to the iliacal vessels. The segmental radiating motory nerve branches are neurolysed and carefully preserved in order to retain the innervation of the musculus rectus abdominis. After complete dissection of the flap graft, the fascia can be easily closed as no musculofascial defect has been caused. Microvascular vessel connection to the internal vessels of the breast is carried out as for the free TRAM.
Adjustment of the transplant and closure of the gastric skin follow an identical procedure as for free TRAM.
Perforator flaps were introduced for autologous breast reconstruction in order to avoid defects in the gastric musculature arising from pediculate and free TRAM flaps. These flap transplants have the same dimensions as the other hypogastric flaps. The advantages of these free microvascular transplants are the same as for the free TRAM, that is excellent perfusion via the inferior epigastric artery system as well as good shaping for breast reconstruction. The decisive advantage is the significant reduction in donor site morbidity.
Periareolary skin-conserving mastectomy (complete removal of the gland). The small picture shows the removed gland and the attendant removed axillary lymph nodes Level I and II.
Dissection of a DIEP flap (Deep Inferior Epigastric Perforator Flap) from the hypogastrium with the attendant inferior epigastric artery system. No muscle is dissected, only skin and fatty tissue.
Condition following periareolary skin-conserving mastectomy on the right and immediate reconstruction with a DIEP flap. A skin monitor is left from the hypogastrium in the place of the former areola.
Condition following periareolary skin-conserving mastectomy on the right and immediate reconstruction with a DIEP flap. Completed mamilla and areola reconstruction from the remaining skin monitor.
Closure of the gastric skin wound after dissection of the DIEP flap.
Condition after mastectomy on the right.
Diagram of secondary reconstruction of the right breast with a DIEP flap before nipple and areola reconstruction. Since the skin covering also has to be replaced in secondary reconstruction, more visible scars result than in primary reconstruction after periareolary skin-sparing mastectomy.
Diagram of secondary reconstruction of the right breast with a DIEP flap after nipple and areola reconstruction.
Closure of the gastric skin wound after dissection of the DIEP flap.
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