Performing DIEP flaps with a Difference

A DIEP flap is a complex 6-12 hour procedure with the end result being the creation of a new breast made from the skin and fat from the abdomen. Apart from the final appearance of the reconstruction and the abdominal scar, there are some other aspects of the surgery that while not apparent immediately after the surgery, will improve the final outcome of your surgery. DIEP procedures performed by Dr Teh and his team aims to achieve the best possible outcome for you by paying due attention to the finer aspects of the procedure.

During the surgery, the aesthetics and symmetry of the reconstructed breast is a priority and time is taken to sculpt and position the flap to achieve this. There are instances where symmetry cannot be achieved ie where the other breast is very ptotic(droopy) or if one of the breasts has been irradiated. In these cases, a second operation may be required (ie reducing or lifting the other breast) to achieve symmetry.

Much care is taken during the microsurgery to minimise trauma to the chest wall. Where possible, Dr Teh will avoid removing a portion of rib for access to blood vessels (internal mammary artery and vein) underneath the rib to perform the vascular anastomoses (ie joining up to the blood vessels of the DIEP flap). Instead he has on many occasions perform the join to a perforating branch above the rib or he will perform the join in-between the rib spaces. In some instances, he will perform the vessel join to the side of the internal mammary vessel under the rib instead of dividing the vessel. The allows the internal mammary to be available for future operations.

In the abdomen, great care is taken to minimise trauma to both the rectus muscle and the segmental nerves that innervate the muscle. While it is much quicker to raise the flap by ‘hacking’ through muscle and nerves, preservation of these structures will maintain your core strength, reduce the risk of chronic pain and minimise the risk of hernias and bulges in the future. Where the nerves are required to be divided in order to harvest the flap vessels, Dr Teh will repair those nerves.

Whilst the location of the final abdominal scar is determined largely by the location of the perforating vessels in harvesting the DIEP flap, there is an emphasis to ensure a nice aesthetic result in the abdomen, in addition to proper healing of the wounds. In DIEP surgery, the abdomen is not uncommonly closed tighter than a cosmetic abdominoplasty, particularly in cases where the abdomen is somewhat lacking in skin/fat. In order to reduce the incidence of wound healing problems, Dr Teh will minimise the degree of undermining as well as ensuring the preservation of the blood vessels to the remaining abdominal skin. Attention is also taken to ensure the creation of an aesthetic umbilicus by the end of the surgery.

Vacuum suction dressings are used over the abdominal scar to further reduce the risk of wound breakdowns and even accelerate wound healing. This dressing is in place for 1-2 weeks following the surgery. Pain catheters are inserted next to the rectus muscle to deliver a continuous infusion of local anaesthetic post op to minimise recovery and allow you to get out of bed sooner. This helps tremendously in reducing complications related to prolonged bed rest (ie pneumonia, blood clots, muscle weakness, and pressure sores) and will speed up your recovery.

Dr Teh does not aim to be the quickest DIEP operator in the country but rather his goal is to maximise your surgical outcome.

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