DIEP and SIEA Microsurgery Flaps

Breast cancer patients increasingly have new options for more advanced procedures. It is now possible to use the patient’s own skin and fat by transforming excess tissue from the patient’s own abdomen into a new breast. The procedure not only removes the excess tissue that would normally be discarded in a “tummy tuck” procedure, but also produces a breast with a more natural and pleasing appearance.

Advanced procedures can be performed by plastic surgeons with special training in microsurgery and perforator flap surgery. The gold standard has become the DIEP (Deep Inferior Epigastric Perforator) flap and the related SIEA (Superficial Inferior Epigastric Artery) flap. These procedures allow plastic surgeons trained in the techniques to take only the skin and fat from the abdomen, without sacrificing the underlying muscle, and transform it into a new breast.

Other procedures, such as a TRAM (Transverse Rectus Abdominis Muscle) flap, are certainly not new; these were described many years before perforator flaps such as the DIEP and SIEA flaps. They involve sacrificing some or all of the abdominal musculature as a byproduct of the breast reconstruction. The muscle itself plays a minimal role in the breast reconstruction and is only used as a carrier for the delicate blood vessels inside. This surgery is now performed only by physicians who do not have the specialized training and experience to perform more advanced abdominal breast reconstruction techniques, or in limited cases where the vessels and small perforating vessels have been damaged by previous surgery or are otherwise poorly present. The chance that muscle may be taken by a more experienced DIEP flap surgeon should be less than 5%.

The preservation of the underlying muscles allows for the abdomen to have an improved shape and appearance and is especially important in active women. Because no muscle is taken, the procedure is also less painful and the recovery is faster. In the hands of an experienced microsurgeon who routinely performs the procedure, DIEP flap complication rates for the reconstructive breasts are no higher than that of a procedure in which muscle is sacrificed.

Patients considering this option must carefully check the credentials of their surgeon. Specialized training and experience in routinely performing DIEP and SIEA flap procedures is highly recommended and the surgeon should be board certified by the American Board of Plastic Surgery.

While insurance companies are federally mandated to provide funding for breast reconstruction, some insurance companies will discourage a patient from pursuing such advanced options because cheaper alternatives only may be provided by their “in-network” providers. Patients seeking this higher level of care should inquire directly with the offices of surgeons that routinely perform DIEP and SIEA flaps. These offices routinely work with most insurance carriers and are quite accustomed to dealing with many of the insurance issues that can and will arise.