Live Surgery DIEP Flap Breast Reconstruction: Houston, San Antonio, Dallas, Austin, Texas
DIEP Flap Breast Surgery
ill dissect down until it meets the medial branch and main trunk. Once we identify this orientation, we will also dissect above the perforator in the superior branch, which you can see in the bottom left hand corner of your screen.
Once we have identified our superior and inferior boundaries of our lateral branch, we then continue our dissection intramuscular and completely encircle the perforator as you see here. Once our perforator is completely dissected down to the branch, we then continue our dissection towards the groin until we encounter the medial branch of the deep inferior epigastric artery and vein. At this point, we will place clips on this deep inferior epigastric artery and vein on the medial side, which will give us access to more length on the artery and vein.
The key to a successful operation in this procedure is minimizing tension and the best mechanism to minimize tension is to allow adequate length of our pedicle dissection. And as you can see here, we are preserving our muscle fibers by tunneling underneath the muscle to gain as much access as we can. And as you can see here, we have one lateral row perforator and we have just now clipped our medial branch, and are tracing this down further into the groin until we approach the external iliac vessel system.
Hence, we have completed our dissection, we will remove our retractors and prepare the operating microscope for vessel anastomoses. We have now gone ischemic, which means we've divided the blood supply to this tissue and we are now orienting our flap in our chest wall such that we can ensure a healthy connection, or anastomosis between the arterial in-flow and the venous out-flow without kinking or twisting. The orientation in these type of procedures is of paramount importance and, again, we want to ensure optimal length and also optimal exposure.
We will then secure the flap to the chest wall to provide stability during our microvascular anastomosis. Now, we begin by bringing the operating microscope into play and cleaning off, under careful microscope dissection ... We have cleaned off the internal mammary artery and vein and now we're beginning work on the deep inferior epigastric artery and vein with a goal in mind of anastomosing the deep inferior epigastric artery and vein to the internal mammary artery and vein.
We are now assessing the size of both the internal mammary vein and the deep inferior epigastric veins, and the DIEP veins have a medial and a lateral component, and based on this patient's orientation, we are choosing to proceed with the medial vein. There are often several branch points, as you can see here, at which point we are dissecting free and placing small microclips to provide enough length and also to prevent any twisting or kinking at these junctures. Therefore, microscopic clips are placed, providing separation between the artery and vein and their subsequent branches. And once this is divided, we will subsequently get more length and identified that our orientation is optimized.
And we are, once again, remeasuring to ensure that our vein is of adequate size and, as we can see here, we have an adequate sized vein, what appears to be a 2.5 mm vein, which will be very adequate for this size flap. Prior to anastomoses, we want to ensure the artery is also clean and free of any fatty material and that also the lateral vein, which we will use as a potential salvage vessel, if need be, is clipped such that there is no bleeding from this point. Once the lateral vein has been clipped, we will subsequently irrigate the whole flap with heparinized saline and we are, first, going to dilate the artery. And utilizing heparinized saline, provide ... Ensure we have adequate in-flow without any undue pressure and it feels to have opened up very nicely and there's easy ... As you can see, the base in there is-
Now, we are ready to proceed with our venous anastomoses. We utilize a venous coupler and this is a beautiful device that allows us to match vessels of different size and discrepancies in a nice, even fashion. With this device, too, we can also utilize what's called an internal doppler where the vein can be ... The coupler itself can be hooked to an internal doppler that is audible through the skin. In this case, however, because we will have to leave a skin island to replace the radiated skin, we do not need this flow coupler, or internal doppler. We are simply just using a standard, routine 2.5 mm coupler. And once we have ensured that the vein is adequate position, we will clean the internal surface to ensure that there is not clot visible, or any debris that can potentially harm or be a source of issue with the anastomosis.
Subsequently, with a gentle motion, we close the coupling device and gently dislodge the coupler. At this point, we will confirm that the coupler is appropriately squeezed and in position, which it appears to be, and then we will reconfirm our orientation and set up for our arterial anastomosis. Artery being of a thicker intima, or a thicker walled vessel, does not allow for a coupling device and therefore we use a standard sutured anastomoses. Once the artery of the deep inferior epigastric artery and internal mammary artery have been aligned, we will confirm orientation and reapproximate the edges.
Using standard 9-O nylon suture, we do an interrupted anastomoses to provide optimal hemostasis and water tight closure. The sutures are smaller than a human hair, and therefore require use of extensive loup magnification, or an operating microscope in this fashion. And in this case, we are using a surgical assistant to provide help with cutting of suture during the microscopic anastomoses and utilizing a first assist and a second surgeon, we are able to optimize efficiency in the OR and have beginning of our second flap dissection while we are performing the microsurgery for our first flap. This can accelerate the surgery with optimal efficiency and still maintain the highest level of quality of care, and allow for a quicker recovery, less downtime, and safer overall hospital stay.
Again, once this [inaudible 00:14:38] position, suture is cut, and this will continue on both sides until we feel that we have confidently obtained a water-tight seal and closure. At this point, we remove our clamps off our vein, followed by our artery, and now we have reestablished perfusion to this flap. We have adequate in-flow through the artery, and out-flow through the vein. We will confirm this with the doppler ultrasound which allows us to identify patency of the artery and vein into the perforators and, upon inspection, in this patient, we find a small adventitial band along the anastomoses, which was subsequently, carefully divided to prevent any kinking, twisting, or clotting of the arterial anastomosis.
And once we are confident with our anastomoses, we also reconfirm our orientation and ensure that the length of our artery and vein are adequate to allow for an easy inset. And a very crucial part of this case is an appropriate inset of the flap, meaning we want the orientation of the flap to be optimized such that blood supply in and out of the flap is optimized and also we want to ensure that the aesthetic result is optimized.
During the initial inset, we generally do not like to remove any of the mastectomy skin for at least 30 minutes after the anastomoses are complete, because during the first 30 minutes is generally when any anastomotic issues or complications will occur. Therefore, we are leaving behind our mastectomy radiated skin for now, temporarily, and then we'll perform our final inset once this time has passed. We subsequently utilize a skin stapler, temporarily, to insert the flap and secure it and to prevent any flap migration.
Once we confirm adequate flap perfusion after 30 minutes of excellent in-flow and outflow, we will spend much time trying to optimize shape in our inset process. This is a very detailed process to deliver our superb results. Again, we are checking for the pedicle to make sure there is no kinling or twisting and orientation is optimized.
We have now begun on our second flap elevation, where we have identified two lateral row perforators and are now circumferentially dissecting around these perforators to allow us to access the fascia and perform our fascial split, which has now been performed. We are using careful loup dissection, as we dissect the two lateral row perforators down to the lateral branch of the deep inferior epigastric artery and vein. We are now approaching the branch point for the deep inferior epigastric artery and vein, lateral branch, and medial branch. And you can see, here, as the flap is being elevated from perforator towards the main pedicle with careful intramuscular dissection. And, at the conclusion, you can see all muscle and fascia has been completely preserved along with the corresponding intercostal nerve bundles.
We perform our closure with permanent suture. In the past, I've previously used an underlay type of mesh to reinforce this, but found that it was of very little utility in the long term. Therefore we perform a primary interrupted varied figure-of-eight suture closure of our fascial edges. Prior to closure, we add Neuropin, a long-acting narcotic. And then after closure, you can see here we have replaced the expanders with the patient's own autologous tissue which will provide a nice, soft breast that will be long-lasting with minimal chance of long-term complications.
This patient has been seen in postop and is very pleased with her end result.
So, there you have it. I hope you found this video educational, both from a standpoint of a patient or a colleague simply interested in how a DIP flap works. We truly believe in this method of reconstruction for the young, healthy patient that wants to attain the most natural, soft breast that reconstruction can offer. I strongly believe in the two-surgeon approach, as I feel I can safely and effectively minimize operating time without sacrificing quality. As you can see in this procedure, we performed this bilateral DIP flap breast reconstruction in about five and a half hours, utilizing a two-surgeon technique.