What Is the Recovery Period for a DIEP Procedure?

I’m getting ready to have reconstruction surgery in Mount Pleasant and the procedure I’m having consists of the tissue being taken from my abdominal area. How long is the recovery period for this procedure versus having the tissue taken from my back?

If the tissue from the abdomen is being transferred as a DIEP flap, you will probably require 4 – 8 weeks for recovery, of which less than one week will probably be spent in the hospital (usually 4 days in our practice). If the tissue is being transferred as a pedicled TRAM flap (in which your abdominal rectus muscle is sacrificed to carry blood for the flap), the time quoted by your surgeon for recovery may be about the same, but some patients may complain of discomfort for considerably longer periods. With either procedure, some patients will heal faster, and some will heal more slowly, not surprisingly.

When you say tissue is taken from your back, I assume you mean a latissimus muscle flap will be used. This is generally done in conjunction with a prosthetic implant being placed, as the latissimus muscle rarely has enough bulk to make a breast by itself. Generally speaking, a reconstruction using the latissimus is easier to recover from than one using the abdomen, because the latissimus is not used constantly for activities such maintaining posture and breathing. Additionally, at least two other muscles, the teres major and the pectoralis major, have functions which strongly overlap the function of the latissimus, and they are able to “take over for it” to some extent. There are no muscles which duplicate the function of the rectus abdominus quite as closely.

—Richard M. Kline Jr., M.D

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Breast Reconstruction Surgeons Answer Your Questions About Reconstructive Surgery

reconstruction optionsThe question below is answered by Charleston breast surgeons Dr. James Craigie and Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

What is the difference between breast reconstruction and augmentation?

Breast augmentation is when you increase the size of a normal healthy breast, almost always with saline or silicone gel implants.

Breast reconstruction is restoring the form of a breast that has been damaged, partially removed, or completely removed. Breast reconstruction is almost always done after treatment for breast cancer, although there are some birth defects that can result in the need for breast reconstruction. Breast reconstruction can be performed with implants (the same ones used for breast augmentation), or with the body’s own excess tissue (usually from the abdomen or buttocks), thus avoiding the need to place foreign objects in the body.

What are the pros and cons of a DIEP versus a TRAM flap reconstruction?

The primary advantage of DIEP flaps over TRAM flaps is a far greater potential for preservation of rectus abdominus muscle function, since no muscle is removed with a DIEP, yet one or both rectus muscles is obligatorily completely sacrificed with every TRAM flap. Additionally, since the muscle does not need to be tunneled under the skin to reach the breast area with a DIEP, the shape of the inferior region of the breast can be better defined.

The primary advantage of the TRAM flap over the DIEP flap is that it can be done by one surgeon who does not have the skills or equipment (microscope and special instrumentation) to perform a DIEP flap. While TRAM flaps can sometimes be performed more quickly than DIEP flaps, this is not always the case, and is very dependent upon the skills and experience of the surgeon. In our practice, DIEP flaps are always performed with two fully-trained perforator flap surgeons present, which we believe contributes greatly to the success and timely completion of the surgeries.

Why don’t more plastic surgeons offer the DIEP procedure?

When the DIEP flap was originally presented by Dr. Robert Allen in the 1990s, it was frequently criticized as being too difficult for many surgeons to learn to perform easily. While many more surgeons now offer the DIEP flap, it is still more technically demanding for the surgeon than many other procedures, and can be quite difficult to learn without spending significant time with another surgeon who has considerable experience with the operation.

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Your Questions About Breast Reconstruction Answered

nipple sparing mastectomyThe questions below are answered by the breast reconstruction surgeons of The Center for Natural Breast Reconstruction, Dr. James Craigie and Dr. Richard Kline:

If a woman has flap reconstruction, are the nipples reconstructed at the same time or at a later date?

While it is sometimes possible to reconstruct the nipples at the same time, usually for various reasons it is preferable to delay the nipple reconstruction until a later time. Nipples must be positioned very carefully to look their best, and that means the final shape of the breast mound must be stable prior to choosing the nipple position. Tissue flaps must be carefully monitored for several days following the initial reconstruction to assure early detection of any problems, and temporarily leaving extra flap skin on the breast mound helps greatly with this. Additionally, FWIW, the skin that the nipples are reconstructed from, whether flap skin or native breast skin, frequently has no sensation, making it even easier to reconstruct the nipples as a small procedure in the office.

If a woman is a candidate for a nipple-sparing mastectomy, can she have flap reconstruction and retain her nipples?

Yes, in many cases. Problems arise when the breasts are very “ptotic” (droopy), especially if the flaps cannot be made as large as the breast tissue that was removed. The nipples can often be saved even in this situation with special techniques (examples include performing a delayed breast lift some months after flap reconstruction with the flap nourishing the nipple, or, in the case of a prophylactic mastectomy, having a breast lift or reduction some months before the mastectomy), but the overall reconstruction is more complicated and prolonged.

Can you explain what you mean by a muscle-sparing free flap breast reconstruction?

“Muscle-sparing” simply means that NO MUSCLE TISSUE at all is removed. This does not necessarily mean that the muscle suffers no injury, as the blood vessels which nourish the flap usually must be removed from the muscle, but the amount of damage is commonly small enough that the muscle ultimately recovers its function.

What are some criteria that may disqualify a patient for breast reconstruction?

Any serious medical conditions which would prevent a patient from tolerating 4-8 hours of general anesthesia would prevent her from having flap reconstruction. Some medical conditions, such as diabetes, increase various risks (in particular, risks of wound healing problems), but do not disqualify the patient from having reconstruction. We do not perform reconstruction on patients who are currently cigarette smokers (or use nicotine in any form) because nicotine’s effects on wound healing after flap surgery is frequently catastrophic. However, most patients will clear all nicotine form their system after a month’s abstinence. Some very slender patients do not have enough donor tissue anywhere on their bodies for flap reconstruction, but this is quite uncommon.

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Is It Normal to Suffer With Abdominal Hernias After Reconstruction Surgery?

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

Is it routine to suffer with abdominal hernias after reconstruction surgery? Is it possible to correct this so there will be no more hernias or surgeries?

Sorry to hear about your problem.

It’s certainly NOT routine, at least not with experienced surgeons doing muscle sparing reconstruction (such as the DIEP flap). Unfortunately, however, it can occasionally happen under the best of circumstances, and we always warn patients about this risk, although I haven’t had a patient with a hernia in several years. Depending on the particular circumstances, it should almost always be possible to fix it, although in the worst cases it could require the implantation of permanent plastic mesh. A worst-case scenario would be a patient who is significantly overweight, with a large volume of intra-abdominal fat, which would push heavily against the muscular abdominal wall from the inside. However, even this situation should be correctable. If your plastic surgeon isn’t comfortable fixing it, then a general surgeon may be (although general surgeons typically refer the WORST hernias to plastic surgeons).

Good luck, and please feel free to ask more questions if you need more information.

—Dr. Richard M. Kline, Jr.

Can I Have My Current Implant Removed to Receive a Muscle-Sparing Free Flap Breast Reconstruction?

dr. richard kline

Dr. Richard M. Kline, Jr.

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

I had reconstruction with implants after my breast cancer diagnosis in 2009. How hard is it to go back and do breast reconstruction with a flap? What would the recovery time be?  Also, does insurance give you a hard time about taking out the implants and revising having a flap?

It’s no trouble at all to remove implants and replace them with a muscle sparing free flap breast reconstruction. We’ve done it successfully hundreds of times. Unfortunately, roughly 30% of women who come to us are seeking conversion from a failed or unsatisfactory implant based reconstruction. Recovery time after flaps is usually 6 – 8 weeks, although some ladies recover much faster. I don’t think insurance usually gives you a hard time—once you’ve started the reconstruction process, they seem to follow through until you are finally content with your reconstructed breast.

—Richard M. Kline Jr., M.D

The Three Stages of DIEP / GAP Free Flap Breast Reconstruction

The below question is answered by Christina Hobgood Naugle, PA-C, of The Center for Natural Breast Reconstruction.

charleston breast surgeons

Christina Hobgood Naugle, PA-C

What are the stages involved in DIEP / GAP free flap breast reconstruction?

The stages of breast free flap reconstruction at our facility can vary depending upon what time in the treatment process we initially meet the patient. The best scenario occurs when the treatment is mastectomy, alone. In those patients, we are able to discuss a skin and possible nipple-sparring mastectomy. This approach means that there is a possibility that the patient would only require one step, although most women are not opposed to a second stage when liposuction, “body contouring,” is involved. Many patients do not have this opportunity, so for them, this process usually involves three stages.

The first stage, being the most involved, is the “technical” stage—the microsurgery element.  After meeting with one of our physicians and discussing the best donor site tissue (tummy, buttocks or inner thigh) the process begins and we relocate the tissue to form a new breast mound. Only the donor site fatty tissue and the blood vessels that nourish that tissue are removed. NO muscle is sacrificed. This blood supply is separated from the body and reconnected to the vessel in the chest wall that once nourished the native breast.

Since the new breast mound is solely relying on the tiny vessels we reconnected initially, we keep you in the hospital for four days to monitor the blood flow into the relocated tissue. This stage of the procedure can require about a six to eight week recovery period, depending upon healing. It varies greatly when women are feeling well enough to return to work or resume the activities they enjoyed prior to surgery.

About three months after Stage One, we may begin discussing each specific patient’s Stage Two.  Three months is the minimum amount of time that we allow. In some cases, we recommend waiting slightly longer than three months (example: radiated tissue, healing issues, or unilateral reconstruction).

Stage Two could be described as the “plastic surgery” side of the breast reconstruction. This is the stage where we fine tune everything that was accomplished in the first procedure, and attempt to improve upon your concerns and how clothes fit. During the first stage, we try our best to achieve symmetry between the two breasts, but sometimes the doctors are limited on the shaping that they are able to accomplish because of the microsurgery portion. Stage Two is about improving symmetry between the two breasts, re-building a nipple if needed, and improving the donor site. This is usually an outpatient hospital procedure but, on the rare occasion, the patient may need to stay overnight.

The procedures performed during this stage vary from person to person, according to their needs. Recovery time varies, too. It could be as little as a day or two weeks, according to the procedures that need to be performed to achieve your desired result.

Three months after your second stage, it is time for your areola tattoo, Stage Three. Women who were able to save their nipple / areola complex at Stage One do not require this stage and are complete at Stage Two. The tattoo is performed in the office under local anesthesia. There is really nothing to this phase. You may drive yourself to the office and expect to be out in one to two hours. It’s really a lot like a social visit and other than exposing your newly tattooed area to public bodies of water like swimming pools, lakes or beaches, there is not much aftercare to speak of. Simple local wound care is all that is required. The risks are minimal and infection and complications are rare.

Many women think of the tattooing as the final hurdle. The best comment I’ve heard was from a woman who stated that after the tattoo healed, she got out of the shower one day and upon looking in the mirror, felt like everything was behind her.

A few other things to keep in mind:

  • Scars look their worse at about three to six months, from that point they should steadily lighten and become less noticeable. It’s hard, but be patient. It takes a while for scars to fully mature and everyone is different.
  • You’ll meet with your surgeon and discuss the best case scenario for you and how to get your breast reconstruction accomplished in as few steps as possible. It is important, even though you are plagued with so many other physicians and concerns, to meet with your surgeon before you have your mastectomy to keep the surgical stages to a minimum. At this point, we’re able to discuss with you your breast surgeon incision site techniques and helpful concepts to improve you final outcome. We also ask your surgeon to weigh the amount of breast tissue removed. It helps for our reconstructive surgeons to know how much breast tissue was removed with your mastectomy and use that number to work toward  rebuilding your new breast, hopefully achieving a symmetrical result earlier in the process to minimize the number of surgical stages.

  • Most patients after the first stage have breast mounds and feel comfortable in clothing. If they must delay State Two of their procedure to undergo chemotherapy, build up time off from work, or just desire time with their family, they are not on a time restriction. (Do keep in mind your deductable.)

  • Vanity is not even a consideration in the breast reconstruction process and these surgeries are not cosmetic plastic surgical procedures. It all comes down to trying to get your body back together and make you as happy as possible, so you can move forward with your life and not have the reminder of everything that you have been through and overcome.
  • Procedures in the breast not affected by breast cancer are insurance covered reconstructive procedures, too. When patients have unilateral reconstruction, achieving symmetry is a little bit more complicated. We have to let the newly relocated tissue settle and heal. The second stage surgical procedures in this case can include, breast lift, reduction, and / or minor procedures to fine tune and attempt to achieve symmetry between the native and reconstructed breast.

We like our patients to discuss with us the things that bother them about their reconstructive result. There are usually things we can improve upon, whether it’s a local procedure in our office or an additional stage. The three stages described in this piece are an outline to the overall process.

Breast reconstruction cases vary and affect each individual differently based upon a number of factors. Some people require one stage and others two or three outpatient or minor procedures to return their bodies back to where they are comfortable and confident.  After you overcome the first stage, the rest are just fine tuning by standard outpatient procedures and local procedures. It is all about making you as comfortable and confident as possible.

—Christina Hobgood Naugle, PA-C