BREAST RECONSTRUCTION
The standard procedure for breast reconstruction using autologous tissue is the DIEP flap. DIEP stands for Deep Inferior Epigastric Artery Perforator flap, which refers to the blood vessel that supplies blood to the flap.
In the DIEP flap procedure, skin and fat tissue from the abdomen (below the navel) is removed, while the rectus abdominal muscles are preserved, so that there is no weakening of the abdominal wall after the operation.
An immediate or primary breast reconstruction is performed simultaneously with the mastectomy. Often, the skin is preserved, and only the "contents" of the breast or the breast glandular tissue needs to be restored. A delayed reconstruction (secondary reconstruction) takes place after a certain period following the mastectomy. In this case, it is often necessary to restore the skin as well.
The DIEP flap consists solely of skin and fat tissue taken from the abdominal region. The abdominal muscles remain intact, which means that there will be no weakening of the abdominal wall after the surgery. Additionally, a blood vessel is removed that remains connected to the skin and fat tissue; this blood vessel is called a perforator.
The removed skin and fat tissue is then transplanted to the chest area. The blood vessel in the DIEP flap is then connected (anastomosed) to the blood vessels that run alongside the sternum.
View the progression of a DIEP flap procedure in this slider. A delayed breast reconstruction after a previous mastectomy is referred to as a secondary DIEP flap. An immediate reconstruction at the time of the mastectomy is called a primary DIEP flap. A primary DIEP flap has the advantage of preserving the original skin.
In the abdominal region, below the navel, the skin and fat tissue are detached from the underlying muscles. This results in a skin and fat tissue "flap" that will be used for the reconstruction of the new breast. The abdominal muscles remain intact, preventing any weakening of the abdominal wall after the procedure.
The surgeon will identify a blood vessel known as a perforator, which includes both an inflow and an outflow vessel. This perforator has been located prior to the operation using an angiographic CT scan. The choice is made for the most suitable perforator, taking into account the course, diameter, and branches, to ensure optimal blood supply to the new breast. A perforator is a smaller blood vessel that originates from a larger blood vessel located beneath the muscle. This blood vessel "perforates" the muscle and branches into the subcutaneous fat tissue.
The fascia (the membrane that surrounds the muscle) around the perforator is carefully incised, after which the perforator is gently detached from the surrounding tissues. This perforator is followed through the abdominal muscle, where a main vessel is encountered that leads further towards the groin region. During the detachment of the perforator, the nerves are protected and preserved to prevent weakening of the abdominal muscles.
The main blood vessel is traced to the groin region and is referred to as the "deep inferior epigastric artery/vein" (DIE). This blood vessel is cut in the groin, resulting in skin and fat tissue that is still connected to a blood vessel. This whole structure is known as the DIEP flap (deep inferior epigastric perforator flap). This blood vessel will now be connected to the blood vessels next to the sternum to restore the blood supply. For this, a surgical microscope is used.
The DIEP flap is now being moved to the chest. Here, the blood vessel of the DIEP flap is connected to the blood vessels located next to the sternum. To gain access to the blood vessels next to the sternum, a piece of rib cartilage may sometimes need to be removed. Using microsurgery, the blood vessels are stitched together. A surgical microscope is used for this purpose.
It is essential to close the abdomen without any tension. One begins by "undermining" the area above the navel and loosening the tissue (skin and fat) from the abdominal wall muscles. This allows the tissue to be moved downwards, so that the abdomen can be closed without tension. A scar forms around the navel; the navel remains connected to the abdominal wall and is repositioned.
The abdominal incision is closed with a resorbable or dissolvable suture. No sutures need to be removed.
The newly reconstructed breast is shaped and modelled as well as possible. Resorbable sutures are also used here.
After breast reconstruction, a waiting period of six months is observed before performing the first correction. The aim of this correction is to optimise the symmetry between both breasts. For this, the non-operated breast may sometimes need to be lifted or reduced. Additional corrections can also be carried out, such as adding volume to the reconstructed breast or correcting scars. Additionally, a correction is often performed at the level of the abdominal scar, or liposuction may take place in the abdominal region.
In some cases, a second correction can be performed three months later; an additional remodelling. Usually, the new nipple is reconstructed, and often this can be done under local anaesthesia.
A nipple reconstruction is not performed using skin grafting. The skin is cut according to a specific pattern. The nipple is therefore reconstructed on-site.
The reconstruction of the nipple can often be performed under local anaesthesia. The complete, outlined pattern is incised (except at the base of the drawing where the blood supply comes in).
One is essentially going to create three skin flaps that will be stitched together with absorbable sutures.
Mobilisation of the three skin flaps.
Mobilising the three skin flaps and stitching the flaps together to create the new nipple.
Suturing the new nipple to achieve a nice projection.
The new nipple was reconstructed.
In the case of opting for the DIEP flap, an angio CT scan of the abdominal region is performed. This is done to map the blood vessels. It provides a clear view of the course of the blood vessels, the quality of the blood vessels, and also shows the location of the blood vessels. This facilitates the procedure and effectively gives the surgeon a "map" of the anatomy.
The hospital stay is typically four to five days. The first night after the procedure, patients remain in the intensive care unit (ICU). The reason for this is not that it is a major procedure, but because the blood flow to the new breast can be monitored regularly (every hour) in the ICU. Most revisions occur within six hours after the procedure. The ICU is located close to the operating theatre, and in case of doubt, immediate intervention can be made.
The recovery afterwards takes six weeks. This means six weeks of relative rest. It is best to avoid lifting heavy weights over 10 kg, as well as to avoid intensive sports activities and driving for two weeks.
The scar is located low in the abdominal region and around the navel. We try to place the scar as low as possible, and this depends on the laxity of the tissues. It is important not to put too much tension on the scar. If this is the case, we place the scar a bit higher and correct it at a later stage.
You wear a support bra for three weeks and you may shower daily (no baths). After being discharged from the hospital, you will receive a prescription for injections to prevent phlebitis for a week. Special ointments or dressings for wound healing are not necessary.
A breast reconstruction with a DIEP flap is a safe procedure. The surgeon involved must have the necessary experience in microsurgery. First and foremost, your health and lifestyle are important. Smoking is absolutely out of the question and can lead to the death of the new breast, significant wound problems, difficult healing, or long rehabilitation. The death of the new breast occurs in approximately 1% of cases. Causes of this include thrombosis or blood clot formation in the blood vessels that supply blood to the new breast. The reason for thrombosis can be technical (difficult anastomosis of the blood vessels or damage caused to the blood vessels) or the formation of blood clots in the blood vessels due to clotting problems or low blood pressures.
Other complications may include: hardened areas in the new breast due to fat necrosis (the death of part of the DIEP flap due to inadequate blood supply related to anatomy), poor wound healing in the abdominal region (due to tension, infection, or blood accumulation), poor wound healing of the new breast (due to infection or previous radiation of the breast), or the formation of distorted scars (hypertrophy).
A weakening of the abdominal wall occurs very rarely in principle, as the innervation of the abdominal muscles is left intact.
After the procedure, you should respect six weeks of relative rest. Avoid intense sports, but walking is allowed. Do not put pressure on the chest by lifting heavy weights, and wear your support bra to support the new breast. You can shower daily, but avoid taking a bath until all wounds have healed nicely. It is best to avoid driving for the first three weeks after the procedure. Eat healthily, especially protein-rich foods that will promote recovery and wound healing.
Our medical team is happy to answer your questions, including those about treatments and fees.
