Deep Inferior Epigastric Perforator Flap: Abdominal Closure and Flap Inset
This video depicts the abdominal closure and DIEP flap inset for a delayed bilateral deep inferior epigastric perforator (DIEP) flap reconstruction in a 53-year-old patient status post bilateral mastectomy for breast cancer.
Authors: Eva Niklinska B.S., Vincent Riccelli M.D., Ashkan Afshari M.D., Stephane Braun M.D., Kent K. Higdon M.D., Galen Perdikis M.D., Julian Winocour M.D.
Affiliations: Vanderbilt University Medical Center
Corresponding Author: Eva Niklinska
Procedure: This video depicts the abdominal closure and flap inset for a delayed bilateral deep inferior epigastric perforator (DIEP) flap reconstruction in a 53-year-old patient status post bilateral mastectomy for breast cancer.
Introduction: The DIEP flap is an autologous form of breast reconstruction following mastectomy, which can allow single-stage reconstruction in contrast to tissue expander reconstruction. DIEP flap chest inset, in conjunction with abdominal layer closure, is the final portion of this procedure.
Indications/Contraindications: DIEP flap breast reconstruction is recommended in patients who wish to achieve breast reconstruction with autologous tissue and have suitable abdominal donor tissue. It is also typically considered a preferred method of reconstruction for patients who have undergone chest radiation. Absolute contraindications include previous abdominoplasty and high-risk medical co-morbities, with elevated BMI, smoking and advanced age considered a relative contraindications.
Materials and Methods: The abdominal layers were reapproximated from the prior dissection of the DIEP flap including the rectus abdominis muscle, anterior rectus sheath, Scarpa’s fascia, and skin. The umbilicus was inset centrally, at the height of the iliac crests through an upside-down “U” incision. The chest DIEP flap inset was initiated with identification of area of bilateral skin Doppler signals. The breast flaps were de-epithelialized and secured with deep sutures and with cutaneous skin paddle inset.
Results: The abdomen was closed without tension to provide an aesthetically pleasing scar and prevention of herniation / fascial defects. The bilateral DIEP flaps were inset, with identification of Doppler signal areas prepared for flap monitoring upon transition to the floor.
Conclusion: This report demonstrates how to perform the critical steps of abdominal closure and bilateral flap inset for a DIEP flap breast reconstruction.
Purpose of technique: According to the American Cancer Society, 1 in 8 American women will develop breast cancer in their lifetime.1 Following mastectomy, many women will consider breast reconstruction. Since the introduction of the Women’s Health and Cancer Rights Act, published trends show an increase in post mastectomy breast reconstruction among US women from 12% in 1998 to 36% in 2011.2 The Deep Inferior Epigastric Perforator (DIEP) flap has now become the most common autologous approach to breast reconstruction. It provides a large volume of soft, malleable tissue that resembles the natural consistency of the breast and allows patients to achieve breast augmentation in one procedure, as compared to tissue expander reconstruction. It is the flap of choice for autologous breast reconstruction because it combines a long pedicle with a relatively straightforward dissection, minimal donor site morbidity, and improves the donor site contour.
Proper patient/case selection (indications): Patients considering breast reconstruction post mastectomy have choices of implant-based and autologous methods. Autologous reconstruction is typically favored in patients who have undergone mastectomy flap radiation. However, patient choice is key in the decision making after thorough surgeon-patient discussion. In an evaluation of patient motives when considering implant versus autologous reconstruction, women seeking implant based reconstruction were more focused on surgical aspects including recovery time and surgical scars, while those considering autologous DIEP flap were more concerned with regaining a breast most resembling their prior breast consistency.3 A study of over 300 women who underwent breast reconstruction concluded that women who underwent autologous breast reconstruction were more likely to be younger (40 -49 years old) and overweight with no significant differences based on race, ethnicity, education or income.4 Patient selection for DIEP flap also favors patients with minimized comorbidities who can withstand a more lengthy surgery.
Contraindications (absolute and relative): Absolute contraindications to DIEP flap breast reconstruction include prior procedures that would compromise abdominal flap integrity including abdominoplasty and large transverse or oblique incisions. Prior abdominal liposuction is not an absolute contraindication, but a preoperative computed tomography should be performed to identify usable perforators. Free flaps are typically relatively lengthy surgeries that require a prolonged anesthesia time, therefore patients should generally be in good health and/or medically cleared for surgery by their primary care provider. Age is typically not important, though patients under the age of 80 are preferred.5 BMI >35 is a relative contraindication. Aspirin and herbal medications, which can inhibit platelet function and clotting, should be discontinued 3 weeks prior to surgery.5 Active smoking is associated with an increased risk of multiple complications, including fat necrosis and abdominal wound dehiscence. If possible, smokers should refrain from smoking for 3 months prior to surgery. In the senior author’s practice, all patients who are smokers are nicotine tested prior to surgery.
Advantages and disadvantages over alternative techniques: In a study of patients who underwent postmastectomy breast reconstruction, DIEP flaps were found to have the greatest overall satisfaction when compared to tissue expanders / implants, latissimus dorsi pedicled flaps and transverse rectus abdominus muscle (TRAM) flaps.6 While implant-based and autologous reconstructions were found to have similar aesthetic outcomes short-term, autologous reconstruction was deemed more aesthetically favorable in long term outcomes (>8 years postoperatively).7 The cost of a DIEP flap is initially higher than implant-based reconstruction, however, this cost diminishes over time with multiple clinic visits for tissue expander fills and subsequent surgery for implant exchange. Disadvantages of the DIEP flap procedure compared to implant-based reconstruction include longer operative time and initial recovery period, additional donor site morbidity and risk of flap necrosis requiring additional surgery. These disadvantages are particularly notable in high risk patients (elderly (>60 years old), advanced disease (AJCC 7th edition stage III or IV), any comorbidities (Charlson score / Deyo Modification) or use of pre- or post-mastectomy radiotherapy with a larger growth in implantation-based reconstruction in recent years.8 Furthermore, nonirradiated chests were associated with better breast sensation post implant reconstruction, while irradiated breasts were found to have better sensation levels post DIEP flap reconstruction.9 This may change with newer resensitization techniques.
Complications and risks: DIEP flap complications include venous congestion, marginal necrosis, and partial / total flap loss. Donor site complications include delayed wound healing, abdominal hernias and abdominal wall bulging.10
Instrumentation: Standard surgical instruments were utilized including both monopolar and bipolar electrocautery. An intraoperative Doppler was utilized for perforator identification. In addition, free tissue transfer required standard microsurgical instruments, including microsurgical scissors, forceps, and needle holders. A venous coupler was used for venous anastomosis. Depending on surgeon preference, there are various techniques that may be used for intraoperative assessment of flap perfusion, ranging in cost from clinical assessment of capillary refill, thermal imaging, to indocyanine green angiography. Postoperative monitoring techniques also largely varies based on surgeon preference. In the senior author’s practice, clinical assessment is typically sufficient, though implanted Doppler probes and flap pulse oximetry (Vioptix) may be used at higher cost.
Setup: The patient was marked preoperatively in standing position. After induction of anesthesia, the major perforators were identified on CTA imaging and marked on the abdomen. Surgical team was divided in 2: (1) Abdominal Dissection and (2) Chest Dissection, working simultaneously to prepare the flap and recipient vessels.
Preoperative workup: Preoperative workup included a reconstructive consultation focused on patient oncologic history and treatment plan (including but not limited to tumor biology, staging, chemotherapy, radiation), comorbidities, and desired outcomes. Physical exam evaluated mastectomy flaps, since delayed, as well as donor sites for scarring and appropriate volume. Review of patient’s prior imaging (mammography, ultrasound, MRI) may prove useful to understand prior tumor location. Further imaging such as CTA or MRA can be utilized to guide assessment of perforator location and viability.11,12 Patient may need initial “babysitter” tissue expander placement prior to DIEP flap reconstruction to preserve the mastectomy pocket.
All patients at our institution received pre-operative abdominal CT angiogram for planning and perforator selection. The largest dominant perforator(s) are selected based on imaging. Perforator selection is also influenced on whether the DIEP flap is a unilateral or bilateral as well as intraoperative doppler assessment, palpability and visual inspection prior to final selection. Flaps are ideally based on a single dominant perforator, however, if there is any question about vascularity, intra-operative imaging can be utilized for assessment and additional perforators included if needed.
Anatomy and landmarks with figures:
Figure 1: Layers of the Abdominal Wall13
Layered closure of the abdominal wall requires reapproximation of all tissue layers, without tension, in order to provide an aesthetically pleasing scar and inset of the patient’s umbilicus. Functionally, the goal is the prevention of hernia or fascial defects / weakness. The necessary layers of closure include the rectus abdominis muscle, anterior rectus sheath, Scarpa’s fascia, and skin.
Detailed steps to procedure:
The abdominal flap closure is facilitated by central dissection up to the xyphoid process with limited lateral dissection, akin to an abdominoplasty. The split rectus muscle made from the pedicle dissection was first closed with 2-0 Vicryl suture in a figure-of-eight fashion. This reapproximated the muscle and distributed the tension across a wider knot than a simple interrupted. The fascia was then closed with a row of figure-of-eights 2-0 Vicryl sutures, followed by a running barbed 0 PDS suture. Two suction drains were placed and secured by external drain stitches. The abdomen was then irrigated with sterile saline.
In order to facilitate further skin closure, the operating table was flexed in a “beach chair” position. Scarpa’s fascia was closed with 2-0 Vicryl sutures. The deep dermis was then closed with 3-0 monocryl. Finally, the skin was closed with running 3-0 barbed monoderm, and dressed with Dermabond.
The abdomen was then marked for umbilicus inset, noting marking staples indicating abdominal midline. The upside down “U” marking and incision at the height of the iliac crests was made centrally. This area was defatted, allowing the umbilicus to be brought through. The inferior flap of the “U” design was used to prevent the umbilical inset from being a concentric circle. The umbilicus was then inset with 3-0 monocryl and half-buried horizontal 5-0 fast-absorbing suture.
For the breast inset, the upper and lower mastectomy skin flaps were approximated with staples, leaving a small “eye-shaped” opening, which contained epithelia from the original abdominal flap. This area was marked with a 5-0 Prolene suture, allowing for identification of bilateral skin paddle Doppler signals.
The approximated staples were removed, allowing the breast flap scarpas layer to be secured to the IMF and chest wall via deep 2-0 Vicryl sutures. The flap was de-epithelialized to prevent epithelial cysts, leaving the small planned cutaneous skin island containing the Doppler signal suture. A 15- French suction drain was placed in each breast, secured by external suture. The breast was closed using 3-0 monocryl buried deep dermal interrupted sutures, followed by a running 4-0 Stratifix Monocryl and Dermabond. Sterile antibiotic dressing was applied to each drain site, while xeroform and an eyepatch were used to cover the umbilicus.
The optimal bilateral DIEP flap inset and abdominal closure consists of healthy, well-perfused flaps with minimal flap tension inset, as well as a secure closure to the abdomen. Negative flap outcomes include total or partial flap loss due to venous congestion or angiosomal perfusion, venous / arterial thrombosis, hematoma, infection or fat necrosis. Negative abdominal outcomes include partial or complete umbilical necrosis, wound healing problems, hematoma, infection, fascial dehiscence or hernia. Negative outcomes in either of these categories may require reoperation. One retrospective study of >500 DIEP flap patients found this reoperation rate to be ~16%.14
Figure 2: Post-operative Reconstruction
Critical steps of the procedure: The critical steps of this portion of the procedure are the (1) inset of the bilateral DIEP flaps, facilitated by identification and marking of Doppler signal area for monitoring, and (2) proper identification and closure of the abdominal layers (if possible minimizing tension), facilitated by approximation prior to abdominal dissection, and flexed table positioning. Careful and continuous assessment of flap viability is critical during the final portion of the surgery, as well as postoperatively.
Common modifications: A modification during abdominal closure includes the rare need of mesh placement in closure or re-inforcement of the abdominal fascia in order prevent hernia or bulge. This may be needed if the DIEP flap needed to be converted to a free TRAM or muscle-sparting free TRAM. With regards to flap inset, depending on the elasticity of the lower mastectomy skin flap (immediate versus delayed surgery, radiation effects), the surgeon may use the original mastectomy lower flap pocket and native inframammary fold or alternatively utilize the DIEP flap to recreate the entire lower breast and create a new inframammary fold.
Common pitfalls: A common pitfalls with abdominal closure includes the need for a higher scar placement compared to traditional abdominoplasty due to the need to capture higher DIEP perforator vessels.
Troubleshooting of the technique(s): Troubleshooting for abdominal closure typically entails ensuring closure of the abdomen by placing the patient into a “beach chair” position prior to commiting to the area of abdominal resection.
Limitations of the technique: N/A
Potential further applications of the technique(s): The techniques utilized in this procedure can be applied to any free flap, and its consequential defect. Knowledge of how to perform this procedure is very useful to any reconstructive or aesthetic surgeon as post-mastectomy autologous breast reconstruction continues to grow.
There was no funding for this project and the authors have no financial disclosures or conflicts of interest.
1. DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA: a cancer journal for clinicians. 2014;64(1):52-62.
2. Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide trends in mastectomy for early-stage breast cancer. JAMA surgery. 2015;150(1):9-16.
3. Gopie JP, Hilhorst MT, Kleijne A, et al. Women’s motives to opt for either implant or DIEP-flap breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery. 2011;64(8):1062-1067.
4. Matros E, Yueh JH, Bar-Meir ED, Slavin SA, Tobias AM, Lee BT. Sociodemographics, referral patterns, and Internet use for decision-making in microsurgical breast reconstruction. Plastic and reconstructive surgery. 2010;125(4):1087-1094.
5. Wei F-C, Mardini S. Flaps and Reconstructive Surgery E-Book. Elsevier Health Sciences; 2016.
6. Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plastic and reconstructive surgery. 2010;125(6):1585-1595.
7. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plastic and reconstructive surgery. 2009;124(1):1-8.
8. Albornoz CR, Cordeiro PG, Pusic AL, et al. Diminishing relative contraindications for immediate breast reconstruction: a multicenter study. Journal of the American College of Surgeons. 2014;219(4):788-795.
9. Magarakis M, Venkat R, Dellon AL, et al. Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery. Microsurgery. 2013;33(6):421-431.
10. Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plastic and reconstructive surgery. 2011;127(3):1086-1092.
11. Rozen W, Phillips T, Stella D, Ashton M. Preoperative CT angiography for DIEP flaps:‘must-have’lessons for the radiologist. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009;62(12):e650-e651.
12. Agrawal MD, Thimmappa ND, Vasile JV, et al. Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping. Journal of reconstructive microsurgery. 2015;31(01):001-011.
13. Netter FH. Atlas of Human Anatomy In. 6th ed. Philadelphia, PA: Elsevier Health Sciences; 2006:Layers of Abdominal Wall.
14. Unukovych D, Gallego CH, Aineskog H, Rodriguez-Lorenzo A, Mani M. Predictors of reoperations in deep inferior epigastric perforator flap breast reconstruction. Plastic and Reconstructive Surgery Global Open. 2016;4(8).
Review Deep Inferior Epigastric Perforator Flap: Abdominal Closure and Flap Inset.