The below question is answered by Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

My plastic surgeon told me that I did not have enough excess tissue in my abdomen to have a DIEP. What can I do now?

That’s a common question, thanks for asking. Many women wonder themselves if they actually have enough tissue for DIEP flap reconstruction, and others are told by their plastic surgeon that they do not. When assessing whether or not a patient’s abdomen can meet their reconstructive needs, several factors need to be taken into account.

First, are we talking about reconstructing one breast, or both breasts? Obviously, reconstructing both breasts takes twice as much tissue as reconstructing one breast. When only one breast is needed, it is possible to use both sides of the abdomen to reconstruct just one breast. This is called a “stacked flap,” which utilizes both sides of the abdomen, with two separate blood supplies, to make just one breast. We routinely do this procedure for patients who just need one breast reconstruction, but require both sides of their abdomen to get the size breast that they desire. It’s more complicated than connecting just one blood supply, but our practice has performed this operation well over a hundred times, with excellent success. In fact, we believe that stacked flaps may be less susceptible to fat necrosis (a complication of DIEP flaps where some of the fat, usually on the edge, dies and gets hard) than ordinary DIEP flaps.

Second, in trying to answer this question, the patient’s desired breast size must be taken into account. A patient who wants both breasts reconstructed to size “D,” but who does not have enough abdominal tissue to make a” D” size breast on each side, might have adequate tissue to make a “B” sized breast on each side. In this situation, if “B” sized breasts would not be acceptable to the patient, then we would usually recommend using the buttocks (a GAP flap) as the donor site.

Use of the buttocks for breast reconstruction, particularly for reconstructing both breasts at the same surgery, is significantly more complicated than using the DIEP flap. Fortunately, we have extensive experience with this procedure, having performed it several hundred times with a 99% success rate. If a patient did not wish to use their buttocks as the donor site, then they would still have the option of accepting a smaller breast size from the abdomen, or they may possibly decide to use implants, foregoing autologous reconstruction altogether.

Finally, for the patient who is told by their surgeon that they do not have enough tissue for a DIEP flap, it is worth noting that it can be extremely difficult for a surgeon who does not routinely perform DIEP flaps to properly assess the amount of donor tissue a patient has available in her abdomen. The thickness of the subcutaneous fat, which is the thickness that can be “pinched” between the skin and the muscle of the abdominal wall, is of paramount importance in assessing how large a breast can be made from the DIEP flap.

In addition, the maximum height of the flap also plays a role in determining what size breast can be made. In assessing how “high” a flap can be safely harvested from the abdomen, it is important to look at how much loose skin is present between the belly button and the bottom of the ribs.  If there is a lot of loose skin in this area, then it will stretch downward more easily to close the lower abdominal wound after harvest of the flap, thus allowing for a larger flap to be obtained. Again, precise assessment of the availability of abdominal donor tissue requires a significant amount of experience on the part of the surgeon, and is ideally performed while examining the patient in person, as opposed to simply looking at photographs.

In closing, to determine if a patient has “enough tissue for a DIEP flap,” we must ask these questions:

• Are we reconstructing one or both breasts?
• What size breast are we attempting to reconstruct?
• What is an experienced surgeon’s assessment of how much tissue can be removed from the abdomen?

Only by taking all of the above into account can a meaningful answer to the question be obtained. We believe that effective communication between the patient and the reconstructive team, in this situation and in most others, is often the key to a successful and happy outcome.

—Richard M. Kline, Jr., M.D.