DIEP Flap Breast Reconstruction and Lymph Node Transfer

An elliptical area of skin and fat is removed from your tummy by chasing the supplying blood vessels through your rectus muscle to the femoral vessels in your groin.

Lymph nodes are identified in your groin with their supplying blood vessels. They are elevated carefully to ensure they remain attached to the DIEP flap via these blood vessels. An incision is made under your arm to release any scarring, which may contribute to lymphoedema, create a pocket for your new lymph nodes and identify the blood vessels we are going to attach the DIEP flap to. The tissue is then completely removed, and the artery and vein are reattached to small vessels under your arm.

The rectus muscle is left completely intact, unlike the TRAM flap, where the muscle is included in the reconstruction, risking bulging and weakness of the abdomen, which requires the addition of a mesh. The abdomen is closed in the same way as a tummy tuck, leaving a horizontal incision in the lower abdomen and a small incision around your new umbilicus (belly button). Once the breast flap is reattached to its new blood supply it can be inset to create a breast.

If you are having an immediate breast reconstruction with a skin-sparing mastectomy, then a small circular area of skin from your abdomen will be used to replace your nipple and areola. The remainder of the breast skin will be preserved, and the flap will sit underneath this replacing the breast tissue that was removed by the mastectomy.

If you have already had or are having a full mastectomy (which takes all the breast skin) then the skin will be replaced with a leaf shaped area of skin from your abdomen.

Your incisions will be closed with dissolvable sutures that do not need removing. You will have Prineo waterproof glue-based dressings, which will be removed at approximately 3 weeks. You can shower as soon as you wish and will not need any dressing changes.

A tube (called a drain) will drain off any excess blood or body fluid from your abdomen and breast.

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of possible complications. All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss them. Decisions about cosmetic surgery should never be rushed.

These risks can be divided into the risks specific to the surgery and the risks of anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

• Unintended intraoperative awareness, which is very rare
• Dizziness and nausea
• Sore throat
• Damage to teeth or mouth
• Nerve injury due to body positioning
• Allergic reaction or anaphylaxis
• Malignant hyperthermia, which is a rare life-threatening condition

The anaesthetist will go through these risks in more detail prior to your surgery.

Scars: Scars are in the lower abdominal crease and run from hip to hip. Depending on the exact type of mastectomy, the breast scars will be slightly different. The main options are:

• A leaf shaped scar on the breast at the edge of the skin paddle if a total mastectomy is performed and skin and breast tissue has been removed.
• A circular scar around the edge of the skin paddle from the abdomen used to recreate the areola if a skin sparing mastectomy is performed with removal of the areola and nipple.
• A scar in the crease under the breast if a nipple sparing, skin sparing mastectomy is performed.

These tend to settle remarkably well; however, some people heal with thicker scars than others and this can make them more noticeable.

Bruising and swelling: A degree of swelling and bruising is normal, and this may take approximately 3 weeks to settle.

Haematoma: This is clotted blood that collects in the breast or abdomen. It occurs in between 1% to 4% of women who undergo breast surgery. It tends to occur within 4 to 6 hours post-surgery.

Any increase in swelling or pain should be reported immediately for assessment. Should the haematoma be significant, it will have to be washed out in theatre and any bleeding vessel(s) identified and cauterised. This does not normally delay your recovery or change the cosmetic result.

Infection: The risk of infection is inherent with any surgical procedure, albeit very uncommon in elective breast procedures. Antibiotics are administered during surgery and for 10 days after surgery to minimise the risks. Less than 1% of patients develop an infection post-operatively and rarely require any intervention, apart from further antibiotic treatment.

Numbness, reduced sensation or oversensitivity: A reduction in sensation in the abdomen and breast occurs in most patients and often recovers to some degree, although it may never completely recover. Occasionally patients feel that nipples become more sensitive.

Wound healing problems: These are rare but can occur around the nipple, at the T junction (where the horizontal and vertical scars meet) or the abdomen. These healing difficulties can range from minor problems, such as small scabs or areas of wound separation, to major issues, such as skin or nipple loss. Although very rare, skin grafting to close the wound may be required thus resulting in further surgery.

Patients who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Seroma: This is a collection of clear fluid under the skin, which sits in a pocket on the abdomen. This spontaneously reabsorbs over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Lymphocele: This is a collection of clear fluid under the skin, at the donor site, which sits in a pocket. It is because of cutting some of the lymphatics from where the nodes are harvested. This normally reabsorbs spontaneously over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Lymphoedema of the donor limb: In theory this should not happen, as we do not harvest the lymph nodes that drain the limb. However, there is a small risk that this could occur.

No improvement: Whilst a lymph node transfer is normally successful in most patients, it is possible that there is only minimal improvement, resulting in a further surgical procedure being considered.

Dog-ears: These are soft tissue prominences where the scar stops. In most cases these settle over the course of 3 months. A small local anaesthetic procedure may be required to remove any excess that remains.

Asymmetry: Each breast is slightly different and will continue to be so following surgery; remember, “they are sisters and not twins”. However, if you have noticeable asymmetry prior to your surgery, then this can be corrected as part of the surgery as discussed with you.

Further excision: It is possible that when the tissue is assessed under the microscope, the lesion has not been completely excised. In this instance, more tissue may need to be removed in a second operation.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for cosmetic surgery is less than 1%, but in order to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

Flap failure: DIEP flaps are very reliable with an excellent blood supply in most patients. We use an ultrasound scan to assess the blood vessels prior to surgery, thus highlighting any issues that may change the clinical decision to proceed with a DIEP, although this is very rare.

There is a risk that the blood supply will not be adequate to keep the tissue alive, or there is a problem with the blood supply after surgery, causing the flap to die or partially die. However, this occurs in less than 1% of patients and if this is the case, we would need to consider another reconstructive option.

Fat necrosis: Sometimes areas of fat within the breast scar and form hard lumps called fat necrosis. Usually, no specific treatment is required, and the problem settles down over a 12-month period.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss these with me.

Decisions about surgery must never be rushed and requires personal research.

Your incisions will be closed with dissolvable sutures that do not need to be removed. I use a glue and tape dressing (Prineo), which is waterproof and can be peeled off between 2 to 3 weeks after surgery, when it starts to lift at the corners. You can shower as soon as you like after surgery and do not require any dressing changes.

I recommend that you wear a support bra for 6 weeks and that you purchase 2 bras, so you have one to wear and one in the wash. These are worn continuously for approximately 6 weeks post-surgery, before returning to any bra of your choice. You will need to purchase these prior to your surgery, and I will provide the relevant details in clinic. Details can also be found in the compression garment guide below.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me after 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

Scar advice
Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

When you return home, you should take it easy for the first week or so. Most patients take approximately 3 weeks off from work. You should be able to start driving after 2 weeks, return to the gym for lower body exercises, and begin upper body workouts at 4 weeks.

To help shape and support your breasts as they settle, you will need to wear your support bra continuously for 6 weeks.

Surgical fees are a combination of the hospital costs, the surgeon and anaesthetic fees and any consumables such as implants. In breast reconstruction patients the fees are normally cover by your health insurance, however most patients have a co-pay of 20% and certain policies only cover one breast and half of the other breast. This means you are likely to have to pay towards the cost of your surgery. Any fees will be calculated, and you will be informed of the potential fees at your consultation.

DIEP Flap Breast Reconstruction + Lymph Node Transfer - Nicotine and Surgery

DIEP Flap Breast Reconstruction + Lymph Node Transfer - Compression Garments

DIEP Flap Breast Reconstruction + Lymph Node Transfer - Pre-Op Instructions

DIEP Flap Breast Reconstruction + Lymph Node Transfer - Post-Op Instructions

Dermabond™ Prineo™