The Patient Journey in DIEP Flap Breast Reconstruction
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FEATURE The patient journey in DIEP flap breast reconstruction BY OLIVIER ALEXANDRE BRANFORD AND PAUL ANTHONY HARRIS n the UK approximately 40,000 transverse rectus abdominis muscle pathway and results in a flap success women are diagnosed with (TRAM) free flap and the deep inferior rate of 99.5%. We describe the breast cancer every year. About epigastric perforator (DIEP) free flap, protocol here. 40% of these need, or choose, named after the vascular pedicle that I Immediate versus delayed to undergo mastectomy, where all perfuses it. These procedures harvest of the breast tissue is removed. an ellipse of lower abdominal tissue reconstruction Currently around a third of these and the flap is then transferred to the For most women the whole process of patients choose to undergo breast chest. Unlike the TRAM flap, where diagnosis, mastectomy, reconstruction, reconstruction, two thirds of these at one rectus abdominis muscle is taken, recovery and other treatments such the time of mastectomy (immediate the DIEP procedure spares the rectus as chemotherapy or radiotherapy can reconstruction) and the rest later abdominis muscle which helps to be a very daunting rollercoaster. It is (delayed reconstruction). All patients preserve abdominal strength, halving difficult to make big decisions during undergoing mastectomy should be the likelihood of a bulge or hernia, and this time, such as whether to have offered breast reconstruction as this shortens recovery time. Because of reconstruction at all, or whether to has been shown to increase patient this, the DIEP flap is now considered have reconstruction immediately or satisfaction [1]. the gold standard for free flap breast at a later time. However, studies show There are several options for breast reconstruction and will be the main that immediate reconstruction results reconstruction, which may be divided focus of this article. in better outcomes and improved into implant-based or flap-based patient satisfaction, with less extensive (autologous) reconstruction using the The DIEP flap scarring than delayed reconstruction. patient’s own tissues. Implant-based The DIEP flap was first described in the The main reason for this is that the reconstruction often involves the use literature in 1994 by Dr Robert Allen majority of the skin of the breast can of adjustable saline tissue-expanders from the USA [3]. It is a microvascular be preserved in the form of a skin- initially which usually require free flap using a woman’s own tissue, sparing mastectomy and then re-filled replacement with a definitive silicone composed of skin and fat from the with the DIEP flap. In contrast, when a implant at a later date. Autologous abdomen, without muscle, to recreate delayed reconstruction takes place, the flap surgery uses a combination of a ‘natural’ breast. Contrary to implant- majority of the new breast skin comes skin, fat, and sometimes part of the based reconstruction, once the primary from the abdomen. Women should be underlying muscle. The flap is moved reconstruction and secondary fine- supported and given this information from areas such as the abdomen, tuning are complete, no long-term so that they can make informed upper back, inner thigh, upper hip, input from the surgeon is required. choices at this difficult time. or buttocks to the chest where it is This is because, once transferred shaped into a new breast. For implant- and shaped into the new breast, it Nipple sparing mastectomy based reconstruction, 34% of patients is living tissue which ages naturally Nipple-sparing mastectomy can result suffer complications such as capsular and changes volume corresponding in reconstructions that look very contracture or a foreign body scarring to the patient’s overall body weight. similar to the original breast, with a reaction, which require them to have It has the additional advantage of small scar, usually in the fold under further surgery within five years [2]. leaving a cosmetically improved donor the breast. The indications for this Autologous flaps can be pedicled site, as the abdominal tissue that is are a small tumour, distant from the or free. The most common example transferred corresponds to the tissue nipple, with a sufficient sized breast to of the former is the latissimus dorsi that would be removed during a full get a clear margin. The nipple is simply flap, where donor tissue remains abdominoplasty (‘tummy tuck’). viewed as another margin. connected to the original donor site There is great variation in national via an intact vascular pedicle. In and international perioperative Relative contraindications to contrast, free flaps are completely practice in DIEP flap breast DIEP flap reconstruction detached from the body with division reconstruction, and there is little Slim women with very little abdominal of the vascular pedicle, and then the evidence-base supporting exact subcutaneous fat may not have enough blood supply is re-established using protocols. The Royal Marsden, London donor tissue, but we have found it microvascular surgery techniques. The protocol that has been developed possible to perform this in most cases. two most common free flap procedures for DIEP flap breast reconstruction In these women another excellent for breast reconstruction are the provides a safe and high quality option is the transverse upper gracilis pmfa news | AUGUST/SEPTEMBER 2016 | VOL 3 NO 6 | www.pmfanews.com FEATURE (TUG) flap, which uses one or both seen to reduce flap volume and some have not found this to cause increased inner thighs as the donor site, giving patients have a temporising implant bleeding. the cosmetic donor site result of a while radiation is given, to preserve Patients are asked to remain nil by ‘thigh lift’. the skin envelope of the breast. The mouth from midnight for food; small implant can then be replaced at a later sips of water may be taken up to 6am if Unilateral versus bilateral date with the DIEP flap for an improved preferred by patients. reco nstruction long-term outcome. There has been an increase in bilateral On the morning of surgery reconstructions, partly as a result Counselling and consent Patients arrive at 7.30am on the day of awareness of BRCA1 and BRCA2 Patients are seen at least twice in clinic of surgery, when they are marked up mutations and the ‘Angelina effect’ before surgery. Consent is obtained by the surgical team. This includes [4]. If bilateral reconstruction is to be where possible in clinic prior to surgery. reference points and so not all marks performed using DIEP flaps it must be The pathway, general and specific risks correspond to incisions. Patient done in one operation as the DIEP flap of DIEP flap reconstruction are covered consent is confirmed. Patients are can only be used once. This requires in depth. Specific risks include 0.5% prepared for theatre by the nursing careful planning and preoperative risk of flap failure in our unit, as well as staff and are taken to theatre at 8am. genetic testing in high-risk women. flap fat necrosis, abdominal bulge or hernia. Anaesthesia Patient selection Owing to the long duration of surgery, The importance of appropriate patient Preoperative imaging patients are intubated and ventilated. selection is a well-known predictor of CT angiograms are an essential part of Venous access is gained with a large good outcomes in microsurgery. As a preoperative planning. We have found gauge peripheral line on the opposite result, most of the women presenting these to be very accurate in identifying side to surgery as many women will for DIEP reconstruction are relatively suitable abdominal donor site have undergone axillary lymph node healthy apart from their breast perforator vessels, which contributes sampling or clearance. In women who cancer. Advanced age alone is not a to both safety and reduced operating have undergone chemotherapy, this contraindication to surgery as long times. can be challenging and central venous as co-morbidities and general health access may be required. An arterial allow the patient to undergo long and Pre-assessment and line is also sited to monitor blood extensive surgery. Although smoking preparation for the procedure pressure accurately throughout the is not an absolute contraindication, All patients are pre-assessed prior operation, and allow blood sampling smokers are advised to stop smoking to surgery. A thorough assessment in the postoperative period. Blood for at least four weeks before surgery. is essential before anaesthesia, and pressure measurement or intravenous Nicotine-induced vasoconstriction, should follow general principles, cannulae are avoided in any limb carbon monoxide-related tissue including adequate planning of prone to lymphoedema. In addition, a hypoxia, and blood hypercoagulability anaesthesia and postoperative care. urinary catheter and core temperature caused by increased platelet Routine preoperative blood tests are probe are used. Anaesthesia can be aggregation can cause problems with taken (haematology and biochemistry, maintained using a volatile anaesthetic breast skin flap vascularity and donor group and save). Standard clinical in oxygen-enriched air or a propofol site morbidity. Similarly, obese patients photographs are obtained and patients infusion. having delayed reconstruction may be are advised to stop smoking. advised on weight reduction methods Patients are asked to obtain a Patient positioning, comfort before surgery to improve surgical loose-fitting sports bra to bring in for and deep venous thrombosis outcome. Absolute