PROCEDURES20Free Flap Reconstruction

I perform the DIEP (Deep Inferior Epigastric Perforator) flap in a very unique way. There are three main benefits to my technique, which I call the minimally invasive “DIEP flap” (can be done in most cases that are carefully selected).

The first benefit is not violating the abdominal wall strength layer, which prevents hernias in the future, and is one of the worst complications from the traditional DIEP flap. The artery that supplies the flap for breast reconstruction is found deep under the muscles of the abdomen, and in order to harvest the flap in the traditional technique, I use the superficial system of the artery and vein. This flap is called the SIEP (Superficial Inferior Epigastric Perforator) flap.   Many surgeons go straight to the deep system, I however, take the time and effort to try to use the superficial system. If the superficial artery and vein are used, the strength layer of the abdominal wall is not violated, and long term hernias are avoided. Many patients ask me what are the major complications from the procedure, and I always point out that abdominal (ventral) hernias are the most devastating complication. Other complications include hematoma, infection, incision breakdown with a subsequent wound, horrible scars such as keloids and hypertrophic scars, and asymmetry to name a few.

Second advantage to my technique is the vessels that I used to connect the free flap from the abdomen in the chest do not require removal of the rib or muscles around the rib. In the traditional technique most surgeons remove part of the rib to access the internal mammary artery and vein, which are big vessels to connect the free flap. However, when patients ask me the major problems with this procedure, I tell them that the worst thing that could happen is a pneumothorax requiring a chest tube. The technique I use prevents this complication. I use a branch from these vessels that penetrates between two ribs. These branches tend to be small, and for this reason many surgeons do not use them. When these branches are used, I do not remove the rib, I do not remove the muscle between the ribs, and therefore the risk of a pneumothorax is gone. These vessels are small, which makes this technique difficult, but can be done in most cases when carefully selected.

The third advantage is decreased operative time, which also translates to decreased complications. The more time the patient is under general anesthesia, the higher the risks of terrible complications. The technique of “minimally invasive” DIEP flap or SIEP flap requires substantially less time to perform than the traditional technique. Therefore the rates of DVT (Deep Vein Thrombosis), VTE (Venous Thromboembolisms), PE (Pulmonary Embolism), infections, flap survival, and electrolyte abnormalities decrease substantially.

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