DIEP Flap Breast Reconstruction Surgery at MedStar Franklin Square Medical Center.

Hi, my name is Gabriel Del Corral, I’m a plastic
and reconstructive surgeon. I’m part of the MedStar Plastic and Reconstructive
Surgery team. Today we’ll be watching a right-side DIEP flap reconstruction. This
is a deep inferior epigastric perforator flap used for reconstruction using
autologous tissue. And this video is going to show a 65-year-old female patient who
presented after a failed tissue expander reconstruction at an outside hospital
that was referred to me for a later reconstruction. She underwent radiation
therapy to the right side of her breasts and unfortunately developed severe scar
contracture and eventually lost her implant. The DIEP flap reconstruction
will allow her to provide a autologous tissue to reconstruct the breast and
give her a better symmetry. This will also provide her with the ability to
reduce the abdominal tissue from her abdomen in order to improve her
abdominal contour. She had decided to proceed options for reconstruction using
her own tissues. In this picture you’ve seen the injection of lidocaine with
epinephrine to control any superficial bleeding and to provide local
post-operative analgesic control. The patient will also be undergoing a
left-side breast lift in order to create symmetry. Now we have started to perform
the dissection in the right side of the chest. At this point we’re recreating the
mastectomy defect where the patient had a previous expander reconstruction. The
skin has been incised, and we can see in the picture, the pectoralis major
muscle. The skin has been lifted off the pectoralis major muscle and retracted inferiorly. This will allow us to create a new space for placement of the
autologous tissue. The patient has had a previous post-mastectomy radiation
therapy. And you can notice the amount of scar tissue that this has created
between the muscle and the skin. That reconstruction will be placed
directly above the muscle, allowing for a natural reconstruction with no animation
deformity afterwards. The pectoralis major muscle has now been split and you
can see a portion of the third rib. The perichondrium of the rib is carefully
elevated off the rib in order to make sure that only the cartilaginous portion
of the rib is exposed. This is done very carefully, as this is a very thin layer
between the rib and the pleura, which is the long space. At the bottom of the
screen the abdominal flap has been elevated off the fascia,
similar to a tummy tuck procedure. This will allow us to bring the superior
abdominal flap down to the inferior black line to provide a tummy tuck or
abdominoplasty result. Here we have removed a small portion of the rib and
you can notice that internal mammary artery and vein has been exposed. These
vessels will be used for later connecting the abdominal tissue to
provide blood supply to the new tissue. Here you can see that there is a vein on
the left side of the screen and a right — and right side of the screen there is a
small artery right adjacent to it. We have now moved to the abdominal portion
of the procedure and the umbilicus is carefully elevated off. A common question
is what happens with the belly button at the time of surgery. And it’s not removed
but is relocated to a new location. The belly button is the same and it remains
attached to the umbilical stalk. Now the flaps are elevated off and you can see
that the abdominal flap is moved medially and with the help of the cautery we
proceed to identify any small vessels going into this portion of tissue. We
call these vessels “perforators” because they perforate the muscle on the fascia
to the fatty tissue. We have now started to open what we call
the abdominal fascia to release each vessel from the muscle. In portion
of dissection, cares to avoid any type of injury to the vessel or to the nerves
that provide innervation to the rectus muscle. Right underneath that abdominal
fascia, you can see that the rectus muscle is shown. Here you can see how the
perforator is released from the muscle. Small branches are clipped to allow for
complete dissection of this vessel. We proceeded to dissect each vessel and we
are now checking with a Doppler that the vessels are actually still viable with
good sound. We have now been able to trace each
individual vessel to their main vessel known as a deep inferior epigastric
shown in this picture. This is a vessel in which will be connected later to the
vessels in the chest. Here each vessel has been completely dissected. You can see
the deep inferior epigastric vessels completely elevated off the muscle. You
can see that on each side of the screen that the entire muscle has been
preserved and the vessel has carefully been teased out for later use. Now the vessel is trisected and the flap
is ready for connection in the chest. You can see in this picture that minimal
muscle or no muscle is taken from this area and the vessel is ready for later
anastomosis and placement in the chest. Here we’re elevating and cleaning each of the
vessels for later use. The vessels are flush with heparinized saline to prevent
any clotting intra-operatively or post- operatively.
Here you can see that the vessels are composed of one artery seen on the left
side currently being dissected and on the right side a vena comitans or a
vein that will be connected as well. Each vessel is flush with heparinized saline
to remove any clotting or debris before connecting them. The operative microscope is brought into
the operating room to allow for micro surgical dissection. Here
the vein is connected using a venous coupler device. This coupler device
allows to fold the vessels of the vein on this small spikes placed on a silicon
disk. You can see that on the right side of the screen the vein of the flap has already been everted and on the left side you can see the
internal mammary vein being everted to allow for coupling. Here the device has been closed and the
vein is completely reapproximated. We ensure that the discs are completely connected with
a small clamp and the venous coupling device is removed. We now see the internal mammary artery
and the artery from the flap in the operative field. The edges are trimmed
and prepare for microanastomosis. We now use a 9091 suture to perform the
connection of both arterial ends. This is a magnification of approximately
10x. The suture is actually smaller than a hair. The clamp is now released. Then anastomosis is checked for any leaks. You can see pulsatile flow in the anastomosis
revealing a patent anastomosis flowing all the way through the right
side of the screen where the pedicle enters the flap. We can also appreciate
flow through the veins behind the artery. After the anastomosis is performed using
the microscope we use a special dye called ICG. This dye allows us to evaluate
for actual patency of anastomosis. The dye is given intravenously and it binds
to anything with blood in the circulation of the artery. You can see
here the fluorescence of the vessel showing patency of the artery through
the anastomosis and you can see venous outflow with ICG coming out of the vein
revealing a complete circuit. After the connection has been performed we are now
closing the fascial defect on the right side of the screen with sutures.
We’re also removing the excess skin from the abdominal flap. You can see that
there is bright red blood coming from the flap giving us the idea that the flap
is well perfused and the connection that was previously created it’s open. This
flap will be later contoured to provide the reconstruction. The opposite portion of skin and
subcutaneous tissues is removed from the left side of the abdomen and the skin is now
ready for closure. The flap is ready to be inset on the right side of the chest.
The mastectomy pocket has been recreated and we use skin staplers to tailor tack
temporarily the flap into the chest wall. This will allow us to really determine
the aesthetics of the breasts and to make a comparison to the opposite side.
The flap is sutured into the inframammary fold and rotated medially in order to
provide enough cleavage for reconstruction. After the flap has been
in set we are now checking for a Doppler pulse. You can hear the presence of a
pulsation on the flap and this is marked with a small stitch in order for
post-operative monitoring of the flap. Next we then proceeded to close the
abdominal wound. This is closed in several layers before we use a series
of sutures known as progressive tension sutures to allow us to bring the
abdominal flap together and avoid the use of any drains with very similar
principles that we would use for an abdominoplasty or tummy tuck procedure.
The skin is tailor-tacked together with staples. The skin is marked just to show
the number of sutures used to obliterate the dead space and bring that superior
abdominal flap down into the abdominal fascia. The flap is checked multiple
times for perfusion. Here again is evaluated with the Doppler. We’re now
performing the abdominal skin closure. This is a three-layer closure in order
to provide a nice aesthetic result. The sutures you use are all dissolvable
sutures. The patient will require to start a scar care regimen approximately four
weeks after the initial surgery. This scar, although it’s a long scar, it
provides a very similar contour as an abdominoplasty scar and we will treat it
as such. During the preoperative markings we ensure that the scar is as low as
possible in order to be able to be hidden under underwear or the bikini line. We’re
now back in the right chest wall where the flap and the orientation of the
pedicle is checked to make sure that there’s nothing kinking the pedicle. Irrigation is performed, we did an antibiotic irrigation before setting up the flap and we are now obtaining some hemostasis
of the flap with the help of the cautery. A drain is placed on the right side of
the chest to collect any fluid after surgery. This drain will be removed
approximately one week after surgery in the office. The flap is now ready to be
inset underneath the previous mastectomy skin that was radiated. This will provide
volume to the upper pole of the breast. The drain is directed away from the
pedicle as shown in this portion of the video. Once the abdominal incision has
been closed, we now proceed to create a new incision on the abdominal flap and
the same but umbilicus that was previously present is brought up through this
portion of the abdominal flap and secured anteriorly. These sutures are all dissolvable
sutures that would not require later removal. We now bring an ICG SPY machine
into the operating room. In this portion of the video,
ICG’s shown on the picture revealing fluorescence and perfusion of the flap.
It all looks good with good capillary refill, profused circumferentially. Skin
glue is used at the end of the procedure over the incisions to allow the patient
to bathe three to four days after their surgery once they arrive at home. A left
breast lift has been performed and now we’re giving the final contour with a
liposuction cannula. You can see that the volume has been restored to the left
breast that is comparable to the right breast creating a nice cleavage and good
upper poll volume. The patient will then be going to recovery and will require
frequent Doppler checks every hour to ensure that the flap is well profuse. The
usual hospital stay for this type of patient will be around three to five
days. Once they go home they’re allowed to shower and engage in normal
activities without any physical activities such as house chores or
gymnasium. Approximately twelve weeks after the surgery the patient is able to return to their normal activities without any restrictions.
We have now concluded the video. Pain control is a big question for our
patients. For this type of procedure, because of the muscle sparing nature of
the procedure, we’re able to spare the muscle and the nerves that supply that
muscle. The patients are able to recover much faster than the previous
reconstruction known as a TRAM Flap. For this type of patient we usually use a
long-acting bupivacaine that is injected during the time of surgery this stays
for approximately 72 hours with the patient. We have not been able to use any
type of PCA pumps or pain pumps at this time and the patient is able to continue
narcotics for approximately three weeks and at that point they have
discontinued their narcotics. We recommend patients to take at least 8 to
12 weeks off from work, but patients are able to resume the regular activities
much sooner than that time. In this case, this patient has been able to
return to work approximately six weeks after the
original operation. She has had a fantastic recovery and she’s able to
return to her normal activities as a teacher very quickly.

16 thoughts on “DIEP Flap Breast Reconstruction Surgery at MedStar Franklin Square Medical Center.

  1. Awesome job.. now I have a better picture of what I will have to face. Can't wait tho I will take the Lord my father and savior with me.

  2. Totally awsome and fascinating video, showing a very detailed account of sucessful DIEP surgery done on a 65 year old woman.

  3. Really well done and informative video. Length, editing were very helpful for this procedure. We are performing this procedure in the near future. How long did this take start to finish?

  4. Thank you for showing what I am facing. I have a question, however, about the nipple. The breast doesn't appear to have a nipple on the final showing. Was the nipple excluded? Was it added back at another time? Can you clarify the nipple for me? Thanks.

  5. I'm grateful for this video. I had a double mastectomy 3 yrs. ago & am going tomorrow for this reconstruction. I feel better knowing these details now. But I'll miss my line dancing during recovery time. I'm 71 & very active.

  6. Thank you so much for this video. It provides a lot more information for me as I consider this option. Your narration was very clear and I am very happy to hear that your patient was able to return to work after a successful procedure.

Leave a Reply

Your email address will not be published. Required fields are marked *