Overview
Definition:
DIEP (Deep Inferior Epigastric Perforator) flap is a free flap breast reconstruction technique that utilizes abdominal skin and subcutaneous tissue, powered by perforating vessels from the deep inferior epigastric artery (DIEA) and vein (DIEV)
Recipient vessel selection is crucial for successful flap anastomosis and perfusion.
Epidemiology:
Autologous breast reconstruction, including DIEP flaps, is increasingly common
The choice of recipient vessels impacts operative time, success rates, and potential for complications
Patient anatomy, prior surgeries, and surgeon preference guide vessel selection.
Clinical Significance:
Optimal recipient vessel selection is paramount for ensuring adequate blood supply to the free flap, thereby minimizing the risk of flap failure, necrosis, and associated morbidity
It directly influences the long-term aesthetic and functional outcomes of breast reconstruction.
Indications Contraindications
Indications:
Breast reconstruction following mastectomy (immediate or delayed)
Suitable for patients with adequate abdominal tissue and no contraindications to abdominal surgery or microsurgery
Patients seeking a natural breast mound with autologous tissue.
Contraindications:
Previous extensive abdominal surgery (e.g., multiple scars compromising perforator blood supply)
Significant abdominal wall weakness or hernia
History of radiation to the chest wall impacting recipient vessel viability
Uncontrolled comorbidities that preclude major surgery
Inadequate perforator anatomy identified preoperatively.
Preoperative Assessment
Patient History:
Detailed surgical history, especially abdominal and thoracic surgeries
History of smoking, diabetes, hypertension, and medications (e.g., anticoagulants, steroids) that affect vascular health
Assessment of body mass index (BMI).
Physical Examination:
Abdominal examination to assess skin laxity, subcutaneous tissue thickness, and presence of scars
Palpation for abdominal wall integrity
Examination of the chest wall for suitability of recipient vessels, including presence of palpable arteries and veins.
Imaging:
Computed tomography angiography (CTA) or Doppler ultrasound is essential to map perforator anatomy, measure vessel diameters, and assess their origin from the DIEA/DIEV
This helps in planning and confirming the suitability of recipient vessels
Preoperative marking of perforators based on imaging is critical.
Recipient Vessel Considerations:
Availability of a suitable artery and vein of adequate size (typically >1.5-2 mm diameter) and quality
Proximity of the chosen vessels to the flap pedicle to minimize tension on the anastomosis
Absence of significant atherosclerosis or previous venous stasis in the selected vessels.
Recipient Vessel Options
Chest Wall Vessels:
Internal mammary artery (IMA) and vein: A common choice, especially if the DIEA is compromised or in patients with prior abdominal surgery
Originates from the subclavian artery
Requires careful dissection and ligation of branches
Provides robust arterial supply.
Thoracodorsal Vessels:
Thoracodorsal artery and vein: An alternative option, originating from the axillary artery
Often used when IMA is not ideal or unavailable
May require longer pedicle dissection.
Intercostal Vessels:
Intercostal arteries and veins: Less commonly used due to smaller caliber and potential for collateral formation
May be considered in select cases when other options are exhausted.
Axillary Vessels:
Axillary artery and vein: Can be used, particularly if the thoracodorsal vessels are not suitable
Requires meticulous dissection to avoid injury to surrounding nerves and structures.
Anastomosis Technique
Arterial Anastomosis:
Suture of the flap artery (DIEA or its branches) to the selected recipient artery
Typically performed using fine non-absorbable sutures (e.g., 8-0 or 9-0 nylon)
Careful handling to avoid intimal damage and kinking
Location of anastomosis should be free of tension and ideally superior to the venous anastomosis.
Venous Anastomosis:
Suture of the flap vein(s) (DIEV or venae comitantes) to the recipient vein(s)
Usually performed using 7-0 or 8-0 non-absorbable sutures
Two-vein anastomosis is often preferred to enhance venous outflow and reduce congestion risk
Anastomosis should be performed inferior to the arterial anastomosis to facilitate venous drainage against gravity.
Technical Considerations:
Meticulous hemostasis is critical
Use of loupes or microscope is mandatory
Adequate vessel length without tension is crucial
Vessel preparation includes adventitial stripping where appropriate
Flow assessment (e.g., Doppler probe) post-anastomosis is essential
Patency is confirmed by capillary refill and venous filling.
Postoperative Care Monitoring
Flap Monitoring:
Continuous monitoring for flap viability using clinical assessment (color, capillary refill, turgor) and Doppler ultrasound to detect arterial inflow and venous outflow
Regular checks (e.g., every hour for the first 24-48 hours).
Anticoagulation Management:
Prophylactic anticoagulation (e.g., low-molecular-weight heparin) may be used, especially in cases with suboptimal vessel caliber or flow
Avoidance of aspirin or other antiplatelets unless specifically indicated and managed carefully due to bleeding risk.
Management Of Complications:
Early detection and management of venous congestion (e.g., by needle decompression, leech therapy, or re-exploration) or arterial compromise (e.g., thrombectomy and re-anastomosis).
General Postoperative Care:
Pain management, hydration, early mobilization, and monitoring for general surgical complications like infection, bleeding, and DVT.
Complications
Early Complications:
Flap thrombosis (arterial or venous)
Venous congestion
Hematoma formation
Wound dehiscence
Infection
Seroma
Partial or complete flap necrosis.
Late Complications:
Fat necrosis
Granuloma formation
Scarring
Asymmetry
Poor aesthetic outcome
Chronic pain
Donor site morbidity (e.g., hernia, bulging).
Prevention Strategies:
Meticulous surgical technique, adequate flap perfusion, careful recipient vessel selection, judicious use of anticoagulation, aggressive flap monitoring, and prompt management of any signs of compromise
Patient selection and preoperative assessment are key.
Key Points
Exam Focus:
Understanding the anatomical basis of recipient vessels and their relative advantages/disadvantages
Knowledge of factors influencing vessel selection
Recognition of potential complications and their management
Key diagnostic modalities for vessel assessment (CTA, Doppler).
Clinical Pearls:
Always have a backup plan for recipient vessels
Never compromise pedicle length excessively
Two-vein anastomosis improves venous outflow and safety margins
Intraoperative Doppler assessment is crucial for confirming flow
Thorough preoperative imaging is non-negotiable.
Common Mistakes:
Selecting vessels of inadequate caliber or quality
Creating tension on the anastomosis
Insufficient flap monitoring postoperatively
Failure to identify or manage venous congestion promptly
Over-reliance on a single recipient vessel option without considering alternatives.