Breast reconstruction (DIEP flap)

About breast reconstruction (DIEP flap)

Treatment for breast cancer often involves lumpectomy or mastectomy and adjuvant treatments such as chemotherapy and radiotherapy. DIEP flap reconstruction uses a patient’s own tissue (autologous) from their abdomen to reconstruct the breast (s). Using this tissue essentially gives the patient a flat stomach like an abdominoplasty (tummy tuck), and as such, is the favoured site for own tissue to be used.

Breast reconstruction empowers a woman to restore their physical appearance, regain confidence, and remove the stigmata of this illness.

What happens during the breast reconstruction surgery (DIEP flap)?

The DIEP (Deep Inferior Epigastric Perforator) breast reconstruction uses a section of tissue from your abdomen which is made of skin and fat. The tissue is transferred to your chest and the artery and veins are connected to blood vessels in your chest wall using microvascular surgery, which is a specialised plastic surgery technique. The tissue is then shaped into a breast. You will have a patch of skin from your abdomen visible on your breast which will be used to monitor the tissue and make sure that your new breast is healthy. In an uncomplicated DIEP flap, the operation should take between 3 and 5 hours. A bilateral breast reconstruction normally takes between 5 and 8 hours.

Following your surgery, you will have a catheter in your bladder so you do not need to get out of bed to pass urine overnight. You will have two IV lines in your arm to allow fluids and medication to be given. You will have anti embolic stockings and calf compressors (which inflate on your calves intermittently to help reduce the risk of you developing clots in your lower legs) (DVT). You will have drains to your breast / axilla (underarm) and your abdomen. Your scars will have absorbable sutures and glue to protect them and they will be covered with dressings.

Hospital stay is usually 4-7 days and most patients are completely recovered by 6 weeks.

Does Dr van der Rijt perform a minimally invasive technique for DIEP harvest?

Yes, Dr van der Rijt performs limited fascial incisions to preserve as much of the abdominal wall tissue as possible. This reduces pain and preserves muscle function as well as reduces the risk of hernia. The limited fascial incision technique is offered to all patients and is routinely performed.

Does Dr van der Rijt perform innervated DIEP flaps?

Dr van der Rijt does no routinely innervate DIEP flaps, however, this is something that Dr van der Rijt can perform and is happy to discuss the pros and cons of innervated DIEP flaps with you during your consultation.

What is the recovery like after Breast Reconstruction Surgery?

The Enhanced Recovery Programme is an evidence-based approach to help improve your condition and recover from your surgery more quickly. This programme is not suitable for all patients and your care will be planned according to your individual needs.

Research indicates that after surgery, the earlier you are out of bed and walking around, and eating and drinking, the better. This will speed up your recovery and reduce the chance of developing complications.

We need you to take an active part in your recovery and work with us. It is important that you talk to us during this time so please ask questions if you do not understand anything.

In Hospital

Day 1

The morning after your surgery will be spent resting in bed, recovering. The warm blanket and will be removed. In the afternoon, the nursing staff and physiotherapist will assist you out of bed. If you are able to walk to the bathroom at this time, your catheter can be removed. The early removal of your catheter will reduce the risk of you developing a urine infection. If you have a pain control pump this maybe stopped and changed to oral painkillers. Regular oral painkillers such as paracetamol and ibuprofen can be very effective and do not have the side effects of morphine-based medication, such as nausea and constipation. Oral morphine tablets are available and prescribed if required. The nurses will continue to check your new breast regularly. If you do not have drains in your abdomen, you should wear supportive pants to protect the wound.

Day 2

Your catheter will be removed and you will be encouraged to walk to the bathroom unassisted. You will be able to shower if you feel up to it - your dressings can be patted dry or dried with a cool hairdryer. If you have drains, they may start to be removed if the volume of fluid is low enough. The physiotherapist will help you to mobilise and give you exercises. Laxatives will be prescribed for you as the medication following surgery and reduction in your mobility may make you constipated. The nurses will continue to check your new breast regularly.

Day 3-4

You will be encouraged to increase your mobilisation around the ward and on the stairs. When your drain volumes are low enough these will be removed (if they have not been removed already). Your surgical team will advise when you are able to be discharged home. Sometimes when the volume of a drain is high, you will be discharged with a drain and asked to measure the fluid daily. You can return to the hospital for it to be removed when the levels are low enough. The ward nurses will show you how to manage your drain. It is important that you continue with regular pain relief and laxatives - a supply of these will prescribed for you to take home.

Going home from Hospital

Following your recent surgery, when you leave the hospital, you should try to rest, however daily gentle exercise (walking) is important and will reduce your chance of developing a deep vein thrombosis (DVT). You should continue to wear your supportive stockings until your mobility is the same as it was prior to your admission. Ease yourself gently back into your daily routine as you feel able. You must remember that you have had major surgery and that your body is still recovering from the effects of the anaesthetic as well as the surgery.

In the early days following your operation, your body will need a vast amount of ‘internal’ energy to repair itself. This leaves you with small amounts of energy for the rest of the day. After each activity you carry out, you may find your energy levels dipping and you may need a rest while your body recovers. As the days and weeks pass, your energy store will increase so that after four to eight weeks you will have returned to your normal daily pattern. During this time, you may find you have a good day when you appear to have lots of energy. This may be followed by a couple of days when you feel tired and sometimes tearful - this is normal.

There are no restrictions to having sex from a medical point of view. Coping with breast cancer and its treatment can be physically and psychologically demanding, and you may well feel tired. You may not feel any desire for sex for a while – this is normal.

Do not drive initially after your surgery, but please ask about resuming this at your first outpatient appointment. Do not to smoke after your operation as smoking will increase the risk of wound breakdown

Do not return to work until you discuss with Dr Rhys van der Rijt during your post operative appointment . This could be up to eight weeks, depending on the nature of your work.

What are the advantages and disadvantages of a DIEP flap (autologous) reconstruction?

Advantages:

  1. Less affected by the effects of radiotherapy compared to implants

  2. Will evolve in shape and size (along with the rest of the body) as a person changes in body weight and ages

  3. Feels more natural than implants

  4. Does not require ongoing attention/maintenance

  5. Avoids risks specific to implants (e.g. rupture, capsular contracture)

  6. For DIEP reconstruction, some patients are pleased with the tummy tuck they receive as a natural consequence of having the reconstruction

Disadvantages:

  1. Potentially longer recovery time

  2. Typically involves a longer surgery

  3. May require an additional scar, depending on where the tissue is obtained (scar fades over time)

  4. Not all patients have sufficient tissue for autologous reconstruction

  5. DIEP reconstruction is a much more complex procedure and may therefore be more costly than implant-based reconstruction .

What are the other options for breast reconstruction?

Breast reconstruction can be performed immediately (at the time of the mastectomy) or delayed (after the mastectomy and cancer treatments.) The decision for immediate or delayed is a shared decision between the patient and the treating surgical team.

Reconstruction can be autologous (own tissue) or alloplastic (implant based) or a combination of both.

Does Dr van der Rijt perform implant based reconstruction as well?

Yes Dr van der Rijt has subspecialty training in breast reconstruction and performs all forms of breast reconstruction.