State-of-The-Art Breast Restoration: The DIEP Flap Tissue Only Option

Because of the procedure’s complexity, only a handful of breast centers across the country offer reconstruction following mastectomy using the muscle-sparing DIEP flap. The revolutionary surgery is now available at Memorial Hermann The Woodlands Hospital.

Janet Mills wants everyone to know about DIEP flap breast reconstruction. Diagnosed with invasive lobular carcinoma at the age of 47, Mills was the first patient to have the revolutionary procedure performed at Memorial Hermann The Woodlands. The date was August 12, 2008, and her surgeons were Bob Basu, M.D., M.P.H., F.A.C.S., and Sugene Kim, M.D., who specialize in advanced tissue-only breast reconstruction using the muscle-sparing DIEP flap.

Mills, who has no family history of cancer, found the lump in her right breast in February 2007. She’d had her annual physical and mammogram just two months earlier. “I assumed that if you had a tumor, it would show up on a mammogram,” she says. “But lobular carcinoma is an exception.”

Her family physician referred her to the Breast and Bone Health Center at nearby Memorial Hermann The Woodlands, where breast radiologist Stephen Rose, M.D., located two tumors with ultrasound. He removed three tissue samples in an ultrasoundguided biopsy; the pathology report showed lobular carcinoma at all three sites. For Mills, the long road to recovery had begun.

Her treatment team included medical oncologist Giuseppe Fraschini, M.D., radiation oncologist Noushin Izadifar Hart, M.D., and breast surgeon Alan Hubbard, M.D., all affiliated with Memorial Hermann The Woodlands. Based on her care team’s recommendations, Mills completed a four-and-a half month chemotherapy cycle before undergoing a right-breast mastectomy in October 2007. She met with board-certified plastic and reconstructive surgeon Dr. Basu immediately to discuss her options and learned she was a candidate for DIEP flap reconstruction, an advanced microsurgical tissue transplantation of excess lower abdominal skin and fat to the chest wall to create a breast mound. Named for the blood vessels that feed the tissue – the deep inferior epigastric perforators – the procedure spares abdominal wall muscles, minimizing the potential for abdominal weakness and discomfort and decreasing the risk of hernia associated with the traditional TRAM (transverse rectus abdominus muscle) flap.

“The DIEP flap is an excellent option for women seeking a reconstructed breast using their own tissue without an implant,” says Dr. Basu, who now performs at least one DIEP flap procedure a week at Memorial Hermann The Woodlands with plastic surgery colleague Dr. Kim. “It’s an advance beyond the traditional TRAM flap in which you harvest excess skin and fat from the belly button to the bikini line, taking abdominal wall muscle and tunneling the excess skin-fat-muscle unit under the skin to bring it to the chest wall to create the breast. The TRAM flap is a good procedure and commonly available. The DIEP flap takes only the excess skin and fat and spares the abdominal wall muscles. For women who are active and want to maintain abdominal wall strength, or those undergoing bilateral reconstruction, the DIEP flap is a great option.”

To perform the surgery, an incision is made along the bikini line, much like the incision used for a cosmetic tummy tuck. The necessary skin, soft tissue and feeding blood vessels are removed, then reattached under a microscope to new blood vessels from the chest wall at the mastectomy site.

Three days after Janet Mills’ surgery, on August 15, 2008, the surgeons performed a bilateral DIEP flap reconstruction on physical therapist Katy Flagge at Memorial Hermann The Woodlands. Like Mills, Flagge had two tumors. Her physician discovered one lump during a physical exam; it was later diagnosed as Stage 1 ductal carcinoma. The second, an invasive lobular carcinoma, was found on ultrasound. Both were in her left breast. She underwent a lumpectomy in December 2007.

“When my pathology report came back after surgery, there were no clear margins,” she says. “My doctors were also concerned about the growth pattern of the lobular tumor. When they recommended a mastectomy, I said, ‘Take both of them.’ I was 48 at the time and didn’t want to worry about a recurrence.”

Flagge went through chemotherapy from January through April 2008, followed by a bilateral mastectomy on May 12, 2008. Like Mills, she had consulted Dr. Basu before her surgery.

“We talked about my options,” Flagge says. “Some women who choose saline or silicone gel implants for breast reconstruction need revision surgery down the road. Then we talked about DIEP flaps. You have to have enough belly fat. You generally have to be healthy. Scarring from previous surgery can interfere with the transplant, so you can’t have had major abdominal surgery in the area where they’ll harvest the tissue. Because I was having a bilateral reconstruction, I was glad I was a candidate for the procedure. I’m a physical therapist, so my abdominal strength is critical to my job. I’ve treated several women who’ve had the TRAM flap, and their abdominal strength is never quite the same.”

At the Center for Advanced Breast Restoration, Drs. Basu and Kim work with women and their physicians to determine a reconstructive plan that aligns with each woman’s needs based on her goals, body type and cancer treatment plan. In addition to tissue only reconstruction, they perform reconstructions with new-generation silicone gel implants and also work with breast surgeons and oncologists using onco-plastic techniques to restore a woman’s breast following lumpectomy.

Options for treatment and the surgery itself vary from one person to the next, and there are pros and cons associated with each procedure. “Implant reconstruction involves a series of smaller interventions over time,” Dr. Basu says. “Some breast surgeons perform a skin-sparing mastectomy. If there’s a skin envelope left, we can place a temporary implant and gradually expand the fluid volume in the implant over a short period of time to stretch the skin to achieve the patients’ desired breast size. Once that’s done, we take the expander out and place the actual implant. But if the tumor is really close to the skin or if the patient is an active smoker, a skin-sparing mastectomy may not be possible.

“Both saline and silicone implants are safe medical devices, but no medical device lasts forever,” he says. “You have the potential risks of implant rupture, scar formation and infection because it’s a foreign body. Women undergoing chemotherapy are immune-compromised so the risk of infection may be higher. When you choose implants, you’re accepting a degree of risk that you may need revision surgery down the road. The exact level of risk is hard to pinpoint and controversial in the literature.”

With autologous reconstruction, patients have a fringe benefit: they get a tummy tuck along with the reconstruction. “But it’s also a more involved surgery,” Dr. Basu says. “DIEP flap reconstruction of one breast normally takes six to eight hours. Bilateral reconstruction requires eight to 10 hours. With the DIEP flap you have a longer recovery time than with implant reconstruction. There’s a small risk – less than 2 percent – that part or all of the tissue transplantation won’t be successful.”

To minimize that risk, patients who undergo autologous transplant reconstruction spend two days in intensive care with hourly Doppler monitoring of tissue vascularization. Once the critical revascularization phase is over, recovery is consistent with that of a tummy tuck.

For Janet Mills and Katy Flagge, the choice was clear: DIEP flap reconstruction offered them the post-op experience they wanted. On October 15, 2008, Mills had the second phase of her reconstruction, which included a left breast lift for symmetry. In November, Dr. Basu used “tissue origami” to form a nipple and tattooing to create the look of an areola. All procedures related to reconstruction are covered by insurance.

“The hardest part of recovery from the DIEP flap is abdominal,” Mills says. “You’re much sorer from the tummy tuck than from the breast reconstruction. But it’s an experience we can live through and go on with life. It’s important that women know they may have this option following mastectomy and that it’s available close to home. We’re fortunate to have the doctors we have in The Woodlands.”

“My patients in The Woodlands and surrounding areas are happy that they have access to state-of-the- art restorations that were formerly available only at the Texas Medical Center,” Dr. Basu says. “For the DIEP flap you need advanced microsurgical technology and a skilled OR staff, and the post-op nursing care is very important. The nursing care is excellent at Memorial Hermann The Woodlands. They’re excited about their patients and monitor them like a hawk.”

Flagge was back to normal six weeks after her DIEP flap reconstruction. “I love that hospital,” she says. “The nurses took great care of me, and I’m very happy with the result of my surgery. My breasts feel like normal soft tissue, and my tummy looks fabulous. What a perk!”

Plastic and reconstructive surgeons Bob Basu, M.D., M.P.H., F.A.C.S., and Sugene Kim, M.D., of the Center for Advanced Breast Restoration are affiliated with Memorial Hermann-Texas Medical Center and Memorial Hermann The Woodlands Hospital. For more information or to refer a patient, contact Dr. Basu at 713.799.2278 or Dr. Kim at 281.363.4546 or visit their Web site at www.breastrestoration.net.

This story was orginially published in Memorial Hermann’s Physicians Advance and was posted with their written consent.