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MUSC Health’s surgeons perform migraine surgery on Denise Stout at Ashley River Tower.

Perforator Flaps

Using flaps of a woman’s natural tissue for breast reconstruction can be done without transferring muscle tissue when the flap includes a perforating blood vessel. Perforator flaps promise optimal cosmetic results without the loss of muscle strength. While procedures vary based on where the perforator flap originates, the general approach usually is the same. A flap of skin, fat, and blood vessels is carefully detached from one part of your body, then reattached and shaped into a new breast at the mastectomy site. At MUSC Health, two surgeons accomplished in complex microsurgery will work together to reconnect the blood vessels, shortening the time of the operation.

One of the most successful perforator flap procedures uses a DIEP flap, which is taken from the abdominal region, where many women have fat and skin to spare. In some cases, though, using the DIEP flap is not always possible, or there may be better options. The decision about which type of flap to use is based on many factors including the amount of tissue available at the donor site, desired breast size, expected scarring, and the patient’s surgical history. We will help you to determine the solution that works best for your situation.

You may not be a flap candidate if:

  • You do not have enough body fat to make the size breast that you desire.
  • You wish to avoid a donor site scar.
  • You have had previous surgeries that have injured perforating vessels.
  • You have a medical condition that limits your ability to withstand general anesthesia for an extended period of time.
  • You require systemic anticoagulation (blood thinners).

Perforator Flap Procedures

DIEP Flap (Abdomen)

While it is a complex process that requires advanced microsurgery, use of the DIEP flap has emerged as one of the most effective and desirable options for breast reconstruction.

The name of the flap comes from the main blood vessel that runs through it – the deep inferior epigastric perforator – which is located in the lower abdomen. During the procedure, an incision is made from hip to hip near the bikini line to access the blood vessels that keep the skin and fat alive. The flap is then disconnected from the abdomen and positioned on the chest.

In contrast to the TRAM procedure, which also draws tissue from a woman’s abdomen, no muscle is relocated with the DIEP procedure. By sparing the abdominal muscles, patients experience less pain after surgery, enjoy a faster recovery, maintain their abdominal strength long-term, and have fewer abdominal complications, such as hernia. No muscle or motor nerves are damaged when the DIEP flap is removed.

As with the TRAM procedure, women who undergo DIEP reconstruction are able to enjoy a flatter abdomen with results that mimic a “tummy tuck.”

Stages of DIEP Reconstruction 

Stage 1: Main Procedure

The purpose of this first procedure is to remove the tissue flap from the abdomen, position it on the chest and keep it “alive.” During this stage, the plastic surgeon will remove the perforator flap from the abdomen, attach the tissue at the mastectomy site, striving to keep the tissue “alive.”

If reconstruction is going to be done at the time of mastectomy, the breast surgeon will leave a pocket where the plastic surgery team can position the transferred tissue. If time has lapsed since your mastectomy, a plastic surgeon will make an incision through your previous scars to create a space for the flap.

Once the flap has been harvested, the plastic surgeons go under the microscope and connect the vessels in the flap to the vessels in the chest wall and under the arm. While the transfer is complex, our plastic surgeons have performed this type of microsurgery hundreds of times, and they operate in pairs so you will spend less time under anesthesia. Reconstruction of one breast (unilateral) generally take three to four hours at MUSC, while reconstructing two breasts (bilateral) takes six to seven hours.

Afterward, you will remain in the hospital three to four days, first in ICU and then a step-down setting. This is not because you are sick – you will be up and walking the day after surgery – but to ensure that you have a nurse dedicated to monitoring the success of the transferred flap. Our success rate with DIEP and other free flaps is 97 to 98 percent.

Your surgeon often can fix minor problems that threaten a flap’s success while you are recovering in the hospital. Once you are discharged, you can expect your flap to live with you for the rest of your life, though the reconstruction is not complete.

Stage 2: Tweaking Stage

This stage is more cosmetic in nature and can be done as soon as three months after your first surgery. The outpatient procedure usually takes an hour and allows the surgeon to address issues with breast and abdominal issues.

If you underwent a unilateral reconstruction, your other breast can be lifted, reduced, augmented or enhanced with fat grafting to create symmetry between the two breasts. If both breasts were reconstructed, your surgeon might do some further shifting or shaping so the breasts match as much as possible. In addition, the surgeon can address scarring or “dog ears” – pointy ends of skin on the side of each hip where the flaps were removed.

Depending on the amount of tweaking that is necessary, nipple reconstruction may be able to be completed in this stage.

Stage 3: Nipple Reconstruction/Tattoo

If it is not done during Stage 2, nipple reconstruction can be completed at this time using local anesthetic in a clinic setting. As early as six weeks after nipple reconstruction, you will return to the clinic for the finishing touch – areola tattooing by our specially trained 3-D artist. The procedures can be scheduled at your convenience and do not have to be done immediately.

CT Angiogram

Before your DIEP breast reconstruction, a CT-angiogram of your abdomen and pelvis will be scheduled. This test produces images of the blood vessels in the abdomen and will help your plastic surgeon map out the defining blood vessels (perforators) and the rest of the abdominal vasculature prior to your surgery.

Before this scan, a contrast material is injected into a peripheral vein. You will then lie on an exam table that slides into the CT machine, a large machine with a hole in the center, and the X-ray tube will rotate around you. Total scan time is generally 20 minutes. You do not have to fast or do anything special to prepare for the CT-angiogram.

Unilateral & Bilateral DIEP Reconstruction

For the sake of symmetry, the DIEP flap is taken from across the abdomen, whether or not the tissue will be used to reconstruct one or both of your breasts. If you are having a bilateral reconstruction, the abdominal tissue will be divided between the two breasts. If you have a unilateral reconstruction, any leftover tissue will be discarded after the procedure.

Once you have had DIEP surgery, you cannot have it again. If you have one breast reconstructed with a DIEP flap and later need or desire reconstruction of the other breast, you will have to use tissue from a different area of your body, or use an implant.

SIEA Flap (Alternative to DIEP)

In some cases, the superficial vessels in a woman’s abdomen provide more blood flow to that area than the blood vessel harvested with the DIEP flap.

When that happens, the surgeon will use the superficial inferior epigastric artery (SIEA) as the main source of blood for the tissue that is being transferred from the abdomen for breast reconstruction.

Removing an SIEA flap is less invasive but is used less often because the corresponding artery is too small in the majority of patients. Your plastic surgeons will decide to use an SIEA or DIEP flap during the procedure once they’ve sized up your abdominal blood vessels.

The procedure for transferring the SIEA flap is otherwise very similar to the DIEP procedure as plastic surgeons use microsurgery to attach the blood vessels in the tissue flap to those at the mastectomy site. Either way, the abdominal muscles are left strong and intact.

Stacked DIEP

For a patient undergoing unilateral mastectomy and who has a combination of larger breasts and a smaller abdomen, all of the lower abdominal tissue may be needed for reconstruction. In this case, the surgery team creates two separate flaps and connects them through microsurgery to create one breast.

DIEP with Vascular Lymph Node Transfer

When lymph nodes under the arm are removed during mastectomy, it may cause the arm to swell (lymphedema). Vascular lymph nodes can be transferred from either the unaffected arm or the groin area to reduce the undesirable side effects. Vascular lymph node transfer can be done simultaneously with DIEP breast reconstruction or as a stand-alone procedure. If done in conjunction with a DIEP, the lymph node and DIEP flaps are harvested surrounding the superficial circumflex vessels in the groin.

Learn more about Lymphedema Management.