FEATURE The patient journey in DIEP flap

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 , 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 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

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(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 contraindications the operation that they don’t mind prophylaxis to surgery are hypercoagulable having a hole cut into for postoperative Careful positioning of the patient states, such as sickle cell anaemia and flap monitoring. This should have no is imperative to avoid peripheral polycythaemia, which greatly increase under-wires, and preferentially do up at nerve damage and pressure sores. the risk of anastomotic thrombosis. the front. Patients are also advised to During the procedure patients are acquire some high-waisted supportive supine on the operating table with DIEP flap breast pants to be worn postoperatively to arms abducted (crucifix position) on reconstruction and radiation support their abdomen. Abdominal padded arm boards supported on gel Contrary to implant-based binders are not routinely used as these pads and gently flexed at the elbows. reconstruction the expected need for can roll up and be uncomfortable. Care is taken to ensure abduction radiotherapy following mastectomy is Preoperative low molecular is less than 90 degrees to prevent not a contraindication for immediate weight heparin (tinzaparin) is brachial plexus injury. Padding is also reconstruction using the DIEP flap. prescribed to reduce the risk of placed underneath the heels, with a If radiotherapy is given following venous thromboembolism. The dose pillow under both knees. At the end mastectomy without reconstruction, is calculated based on the patient’s of the procedure, the patient will be it is best to wait until the acute effects weight. This is injected into the buttock positioned with both hips and knees of radiation on tissues has subsided, or thigh and not the abdomen as the flexed, supported on two or three typically six to 12 months, before flap will be raised from the abdomen. pillows to prevent tension on the further surgery, although this can be Tinzaparin is routinely given the night abdomen. sooner. before surgery. Where this is not Deep venous thrombosis is a risk Radiotherapy has occasionally been possible this is given on induction. We in prolonged surgery. Anti-embolism

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“The DIEP flap is raised at the same time as mastectomy in immediate breast reconstruction, and this shortens the Figure 1: Intraoperative view of DIEP flap viewed from foot of the Figure 2: Intraoperative view of venous coupler operating table. The flap has been reflected to the patients right device on the left of the photograph prior to operating time.” side (to left of diagram) with two vascular perforators (P) shown anastomosis of the veins, one of which is seen as they are dissected through a vertical separation in the rectus held on the right of the picture. abdominis (RA) muscle, seen under the deep fascia (F), which is opened for access to the vessels [5].

Figure 3a Figure 3b Figure 3c

Figure 3. This series of clinical photographs in the same patient shows how a natural attractive breast can be recreated using DIEP flap breast reconstruction. Preoperative view (3a); Preoperative marking (3b); Postoperative view (3c). stockings and cyclically inflating vessels are chosen because of their final adjustments are made. Flowtron® boots (calf-pumps) are used proximity to the breast and excellent The abdominal donor site cavity in addition to tinzaparin as described size match with the vessels of the may be quilted using a ‘barbed’ suture above. flap. Some surgeons elsewhere prefer to reduce the incidence of seroma. to use the blood vessels in the axilla There may be up to two low suction Surgical procedure although this is rare. The veins are abdominal drains placed through the Surgery may be four to eight hours usually connected with a venous pubic area and one to two drains in long, and is longer for bilateral coupler device (Figure 2), whereas the the breast (depending on whether reconstructions. The DIEP flap is raised arteries are usually sewn together an axillary dissection has been at the same time as mastectomy in with sutures that are finer than human performed). The breast reconstruction immediate breast reconstruction, and hair and only just visible with the skin paddle and abdominal wound are this shortens the operating time. naked eye, hence the need for the sutured with absorbable sutures, tissue DIEP flap breast reconstruction microscope. glue is applied to seal the wound and involves three main stages: (iii) Insetting of the flap, shaping of the allow early showering. Micropore® tape (i) Raising of the flap with dissection transferred tissue and abdominal is applied to the wounds. through a temporary vertical split donor site closure. in the rectus abdominis muscle to As the microsurgical success rates Postoperative care meticulously separate out the small are so high the emphasis is placed The patient will be put into their sports perforator vessels originating from the on aesthetic outcome: to this end, a bra at the end of the case and a hole deep inferior epigastric artery great deal of the operation is spent will be cut into it for flap observation. (Figure 1). shaping the new breast. The aesthetic Poor flap perfusion, although rare, (ii) Microvascular anastomosis of the goal should not be simply to create a should be rapidly identified with flap to the internal mammary artery breast ‘mound’, but should reflect the expeditious return to theatre before and vein in the chest using a surgical patient’s desires, recreating natural compromise becomes irreversible. microscope. The internal mammary breast beauty (Figure 3), taking into The patient will initially go to recovery vessels are accessed between the account breast asymmetries and plans and will need flap observations costal cartilages in the chest. These for a second stage of surgery where every 15 minutes for the first four

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therapy, our experience in free flap Flowtron® boots are removed on day breast surgery suggests this is not one postoperatively to allow greater necessary, as fluid losses are not great mobility. The urinary catheter is “The aesthetic goal due to the ‘surface surgery’ nature removed on the second postoperative of the procedure, and due to the day if patients are mobile enough. should not be simply to proximity of the internal mammary Anti-embolic stockings are continued create a breast ‘mound’, artery to the heart, there is excellent until patients are mobile. Tinzaparin is perfusion. Fluid overload is avoided continued for one week postoperatively but should reflect as this increases the risk of flap and two weeks for high-risk patients thrombosis and pulmonary oedema. (including those with high body mass the patient’s desires, Fluid management is initially via index and those undergoing bilateral intravenous crystalloid fluids, although reconstruction). recreating natural these are routinely stopped on the Daily outputs from drains are breast beauty, taking first postoperative day when the recorded, with a total for each 24 patient is drinking to avoid overload. hours postoperatively, with the drains into account breast Vital signs include monitoring routine marked each day at 8am. Drains can clinical observations. Hourly urine come out when less than 30mls in 24 asymmetries and plans output is monitored, aiming for 40- hours if the patient has been sitting for a second stage of 50ml/hr, approximately 0.5ml/kg/hr. out. Drains are removed at three Normally patient care is in intensive days postoperatively unless there is surgery where final care recovery over night for close persistently high output. monitoring purposes. Patients are Patients are discharged from day adjustments are made.” encouraged to drink clear fluids only three, but typically on day four or five, during the first postoperative night. and slightly longer in bilateral cases. Eating and drinking a normal diet may begin the following day after surgical Wound care review. Micropore® tape is left in situ and hours postoperatively and thereafter A Bair Hugger™ air-warming device patients are encouraged to shower every half hour overnight. Flaps is used to maintain normothermia. from day four onwards. Patients are are monitored closely using clinical This normally remains on for 24 hours given instructions about wound care parameters and a hand-held Doppler postoperatively. when they go home and given the device. The following flap observations Pain management is via a number of where to call at all times in are made: flap colour, temperature, patient controlled analgesia (PCA), an emergency post discharge. whether the flap feels soft or firm, with regular anti-emetics being Patients are typically seen on day 10 capillary refill, Doppler signal, and are administered while on PCA, if required. post surgery in our dressing clinic, with recorded on a specific flap chart. In this The PCA is usually removed on day two outpatient review at two to four weeks way any potential venous compromise with appropriate and alternative oral and again at six weeks. (brisk capillary refill (less than two analgesia prescribed. seconds) with a dusky or bluish flap Three doses of intravenous Recovery and possibly increased drain output or augmentin antibiotic (depending Patients are advised not to drive for haematoma) or arterial compromise on penicillin allergy) are routinely four weeks, or until they can perform (a pale flap with reduced or absent administered. emergency manoeuvres, and may Doppler signal) are identified rapidly Routine biochemistry and return to work from six to 12 weeks and are an indication for emergent re- haematinics (full blood count and urea depending on the nature of their exploration. When recognised early and and electrolytes) are taken on the night work. Initially patients may feel some managed promptly (within six hours), of surgery, aiming for a haemoglobin abdominal tightness but are able to compromised flaps have a 75% salvage level of between 8-10g/dl. Blood stand fully upright within a few weeks. rate. The definitive management of transfusion is rarely required. Strenuous exercise should be avoided a struggling or failing flap is usually Patients are on bed rest for 24 hours. for eight weeks to allow the abdominal surgical and patients require urgent During this time we avoid turning donor muscle and fascia to heal fully. re-exploration to inspect the vascular these patients as this may affect the pedicle for kinks and compression, circulation to the flap. Patients should Breast symmetrisation and assess patency of the anastomosis, have knees bent at all times in bed secondary adjustments identify thrombus formation, perform and their head should be no lower It should be remembered that almost embolectomy if appropriate, or than 30 to 45 degrees for the first 48 90% of women have noticeable administer intra-arterial thrombolysis. hours. Patients should not be made asymmetric breasts due to soft tissues Patients are reviewed routinely to lie flat when moving up the bed, or bony chest walls preoperatively. by the on call team and as required. with appropriate numbers of staff to In patients undergoing breast Hourly observations are continued assist the patient during moving, in reconstruction, this may not be noticed from the first postoperative day, as order to reduce abdominal tension. until they have surgery. Around a third guided by the surgical team. Flap Patients are sat out in a chair on the of women want their reconstructions observations are continued until first day postoperatively, with chest to match their unoperated breast. discharge. physiotherapy to reduce atelectasis, The remainder are keen to have a lift While the traditional approach and may be mobilised gently with the () or reduction on the other was for aggressive intravenous fluid physiotherapist the following day. side. Symmetrisation may involve

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liposuction and fat transfer to either 2. Gabriel SE, Woods JE, O’Fallon WME, et al. Conclusion Complications leading to surgery after breast breast. Deep inferior epigastric perforator (DIEP) implantation. N Engl J Med 1997;336(10):677–82. Most reconstructions require more free flap is considered the gold standard 3. Allen RJ, Treece P. Deep inferior epigastric artery than one stage and adjustments to one or in free flap breast reconstruction. As the perforator flap for breast reconstruction. Ann Plast Surg 1994;32(1):32-8. both sides so it is a journey, not a single microsurgical success rates are so high 4. Lebo PB, Quehenberger F, Kamolz LP, Lumenta operation. If the nipple is removed the using The Royal Marsden pathway the DB. The Angelina effect revisited: Exploring a nipple can be reconstructed either by media-related impact on public awareness. Cancer emphasis is placed on aesthetic outcome 2015;121(22):3959-64. ‘sharing’ the other nipple from the other in the interests of patient satisfaction. 5. Nimalan N, Branford OA, Stocks G. Anaesthesia for side if this is large or using the newly free flap breast reconstruction.Br J Anaesth Edu reconstructed breast skin with local References 2016; 16(5):162-6. 1. National Collaborating Centre for Cancer. Early skin flaps. and locally advanced breast cancer: Diagnosis and The final stage is to tattoo the nipple treatment. NICE Clinical Guideline 80. London, UK; National Institute for Health and Clinical Excellence if requested, which can make the final 2009. [https://www.nice.org.uk/guidance/ result look very natural. cg80?unlid=30968466520158613027 Accessed 30 Olivier Alexandre June 2016]. Branford, MBBS, MA(Cantab), PhD, MRCS(Eng), FRCS(Plast), Locum Consultant Plastic Surgeon, TAKE HOME MESSAGE The Royal Marsden Hospital, London, UK. Declaration of • All patients undergoing mastectomy should be offered breast reconstruction. competing E: olivier.branford@ interests: icloud.com • The DIEP free flap is considered the gold standard in free flap breast None declared. His areas of professional interest reconstruction. are breast reconstruction, aesthetic breast surgery. • The DIEP free flap is a microvascular free flap using a woman’s own tissue, composed of skin and fat from the abdomen, without muscle, to recreate a breast Paul Anthony Harris, that looks and feels natural. BSc, MD, FRCS, FRCS(Plast), Consultant Plastic Surgeon, • The Royal Marsden protocol that has been developed for DIEP flap breast The Royal Marsden Hospital, reconstruction provides a safe and high quality pathway and results in a flap London, UK. success rate of 99.5%. His areas of professional interest are breast reconstruction, • Most reconstructions require more than one stage and adjustments to one or aesthetic breast surgery. both sides so it is a journey, not a single operation. Declaration of competing interests: None declared. • Once the reconstruction is complete there is no need for long-term ‘maintenance’.

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