The Deep Inferior Epigastric Perforator flap (DIEP flap) replaces the skin and soft tissue removed at mastectomy with tissue that is borrowed from the abdomen. A slim incision along the bikini line is made, much like that used for a tummy tuck. With a DIEP flap the skin, soft tissue, and very small blood vessels required to produce the breast reconstruction are removed from the abdomen. These small blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope. Unlike conventional TRAM (Transverse Rectus Abdominis Muscle) flap reconstructions, the use of the perforator flap technique allows the collection of the required tissue without sacrifice the underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is a favorable donor site for many woman, since excess fat and skin are often found in this area. In addition to reconstructing the breast, the contour of the abdomen is often improved, much like a tummy tuck.
Like the DIEP flap, the Superficial Inferior Epigastric Artery (SIEA flap) flap replaces the skin and soft tissue removed at mastectomy with tissue from the abdomen. In a select group of women the blood vessels just under the skin are used as feeding vessels for the abdominal skin and fat. The use of these superficial vessels allows the surgeon to completely avoid the abdominal muscles because the blood vessel used do not travel within the muscle. The vessel supplying the lower abdominal tissue are preserved and the transferred skin and fat are transformed into a new breast mound. The procedure is otherwise the same as the DIEP flap, resulting in a low abdominal incision much like a tummy tuck.
The Transverse Rectus Abdominis (TRAM) Flap is similar in design to both the DIEP and the SIEA flaps. In contrast to the other two flaps, in some situations a portion of the rectus muscle must be taken with the abdominal skin and fat. The decision to remove some muscle is based solely on the anatomy of the patient. Preoperative imaging helps to determine if this will be required, but ultimately the decision is often made in the operating room. The TRAM flap offers similar results in the breast but does sacrifice some muscle to obtain that result. In Dr. Haddock’s practice it is very rare that he has to use a TRAM flap as he almost always can use a DIEP or SIEA flap. If a TRAM is used then the abdominal contour is still similar to a tummy tuck.
Umbilicus (Belly Button)
The umbilicus, or belly button, can be managed many different ways with the DIEP flap procedure. Dr. Haddock has done extensive work trying to limit complications, and one way to do this is to temporarily remove the umbilicus at the time of the DIEP flap procedure. Depending on the specific comorbidities, and anatomy of the patient, this can reduce a 50% or 60% complication rate to near 0%. Dr. Haddock has pioneered a Neo-umbilical reconstruction procedure that can easily be done at the time of nipple reconstruction or any breast reconstruction touch-up procedures. The aesthetic results of this procedure are often superior to keeping the native belly button. Some umbilical reconstructions are shown in the photo gallery.
Double DIEP Flaps (Stacked DIEP Flaps)
Double flaps or stacked flaps is when two flaps are used for one breast. The most common variant of this is a Double DIEP flaps in which both sides of the abdomen are used for one breast reconstruction. This is commonly used in the setting of delayed reconstruction and/or following radiation. The two flaps together can provide more skin and volume to allow total breast reconstruction.
Dr. Haddock and his partner Dr. Teotia have one of the largest published experiences with these types of procedures in the world. They have presented on this in local, regional, national and international meetings.
4 Flap (DIEP Flaps and PAP Flaps)
The 4 flap breast reconstruction refers to bilateral DIEP flaps and bilateral PAP flaps performed at the same time. This is a unique operation that is only employed in specific situations. In a subset of patients the abdomen or thigh alone will not provide enough tissue for total breast reconstruction. By using both the abdomen and the thighs as is done in the 4 flap breast reconstruction we can obtain adequate skin and volume to perform total breast reconstruction. In these complex situations using only one location would compromise the final aesthetic result. The use of multiple flaps avoids this compromise to the breast. Additionally it allows a more conservative surgery at the donor site ultimately limiting the morbidity of the thighs and abdomen.
Dr. Haddock performs these procedures with his partner Dr. Teotia. Together they are pioneers in this procedure and have one of the largest experiences with 4 flap breast reconstruction in the country.
Choosing Your Surgeon
Dr. Haddock has extensive experience with the DIEP Flap. He has performed hundreds of these procedures with very high success rates. Dr. Haddock has performed over 2,000 breast reconstructions with flaps. His approach is focused on a few key goals including superior aesthetic results, limited abdominal morbidity, and operative efficiency leading to quicker recovery. When choosing a surgeon to perform this operation experience is key. Additionally, the focus of the operation can vary among surgeons. Dr. Haddock does not simply view success as flap survival but his goal is to achieve the result his patients desire.
DIEP Flap Recovery
Dr. Haddock typically performs these operations at UT Southwestern Clemens University Hospital in Dallas, Texas. Here he uses an Enhanced Recovery After Surgery (ERAS) Protocol to provide for faster recovery and limit postoperative discomfort.
Patient Comments About a DIEP Flap with Dr. Haddock
"You know you have a fantastic plastic surgeon when your breast oncologist conducts exam and ask if you are staying current on mammograms and then goes "oh wait... You had breast reconstruction. Your plastic surgeon is amazing!" Well, I think so too. Thanks Dr. Haddock!"
"I can truly say that my experience has been wonderful. Dr. Haddock is a great plastic surgeon who takes pride in his work and makes you feel you are in good hands. He is always there to answer any question or concern. I truly recommend him for any type of plastic surgery because he loves what he does and he is good at it."
"I am a breast cancer survivor!! And I can truly say that when I look in the mirror I don't see a daily reminder that I once had cancer that took away the old models of my breast because Dr. Haddock gave me new models that make me feel so good about myself!!"
"I had a DIEP flap and am very pleased with the results. Dr. Haddock was very kind and wanted to make sure I was happy with the results. He discussed options with me that made me feel like I was part of the process. I now refer others to him. I highly recommend him, not only for his surgical skills but also for his caring nature."
"My experience was great with Dr. Haddock. His staff is so kind and his integrity and bedside manner is wonderful. Of course, the best part is the results."
As in all procedures, there are complications associated with autologous breast reconstruction. The potential adverse outcomes of autologous tissue breast reconstruction are total flap failure or partial flap failure. Total flap failure, the most feared complication, typically occurs due to a venous or arterial thrombosis of the vessels supplying the flap. With improved operative technique, in experienced hands this risk is extremely low. Patients may also experience hematomas, seromas and wound healing problems at the donor site or the recipient site.