Procedure: DIEP/SIEA Flap Reconstruction
What is the definition of a DIEP/SIEA Flap Reconstruction Procedure?
The DIEP flap and the SIEA flap are both advanced techniques used in breast reconstruction after mastectomy in which excess abdominal skin and fat are removed from the lower part of the abdomen. The difference between the two is the choice of blood vessels that nourish the flap tissue.
In DIEP flap breast reconstruction, the blood vessels are contained in the abdominal rectus muscle and advanced microsurgical techniques are used to safely separate the artery and vein from the muscle while preserving muscular integrity.
In SIEA flap reconstruction, the blood vessels are more superficial and they travel in the fatty layer of the abdominal tissue. Therefore, less dissection is required than in the DIEP flap, where the blood supply is deeper in the muscle.
Since the superficial vessels may be absent in some patients, the decision as to which flap is performed is made during the reconstructive surgery, based on the patient’s anatomy. In either type of breast flap reconstruction, the abdominal tissue is completely detached from the abdomen and re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer. These tiny blood vessels require the surgeon to use a microscope to connect them together. Once this is complete, the blood flow to the tissue is restored. The tissue is then shaped to fit the mastectomy defect and a small skin patch is left. The skin patch from the abdomen will be used later to reconstruct the nipple. For patients who underwent a complete mastectomy, the abdominal skin is used to replace the missing breast skin.
The skill of the surgeon in breast flap reconstruction is considerably more demanding than earlier methods of breast reconstruction. The operation can be lengthy due to the precise nature of this microsurgical procedure. The surgical effort is rewarded, however, by excellent cosmetic results. The procedure is also less invasive, resulting in less pain and faster recovery. In the case of DIEP and SIEA flaps, the operation leaves a horizontal scar on the lower abdomen, similar to that created in a cosmetic tummy tuck, resulting in a slimmer abdominal contour that is appreciated by most women. Additionally, for both the DIEP and SIEA, we can now offer routine re-innervations where nerves are connected to facilitate gradual return of sensation in the reconstructed breast.
Getting Ready For Surgery
PRE OP INSTRUCTIONS
If you have any questions concerning these Pre Operative Instructions, CONTACT US via email with your questions or call the office 713-441-6102.
Two or More Weeks Before Surgery
Pre-operative Labs: Lab work must be obtained and reviewed prior to surgery. The lab work will need to be completed 3 weeks prior to surgery. You may also be requested to do a cardiac work-up before your surgery.
Medications: Do not take any aspirin containing medication including cold formulas for at least 2 weeks prior to surgery. Please let us know if you are taking or have been taking any herbal supplements or vitamin E. These will need to be discontinued also. Please refer to the Medication List for some frequently used medications that contain aspirin or an anti-inflammatory. These compounds have a tendency to decrease the average clotting capacity and increase bleeding during surgery. Tylenol may be used instead as it does not have these untoward effects. If you are on Tamoxifen, you need to stop taking this medication 3 weeks before surgery.
Smoking: Smoking compromises blood flow by causing spasm of blood vessels and significantly increases the risk of flap complications and wound healing problems. Therefore, DO NOT SMOKE for at least 8 weeks before and 6 weeks after surgery. This also applies to second hand smoke; therefore do not stay in the room with cigarette smokers.
Iron: Iron supplementation with a vitamin C supplement should be started as soon as possible prior to surgery especially when donating blood. Red cells contain a large portion of the body’s iron stores. Therefore, supplementation should be started immediately and continued for at least 2 weeks after surgery. There are several iron supplements available without a prescription. All may cause some gastric distress or constipation, although individual reactions may differ. You may tolerate 1 product better than another. Taking iron supplements with food decreases such symptoms although all are better absorbed on an empty stomach. Avoid taking supplements with milk or calcium supplements, which decrease iron absorption. Some examples are:
- Ferrous Sulfate: usually the least expensive form, well absorbed, can cause gastric distress or constipation (e.g. Slow Fe, Feosol, Fer-In-Sol)
- Ferrous Gluconate: slightly more expensive but causes less gastric distress (eg. Fergon)
- Ferrous Fumarate: similar to ferrous gluconate (eg. Ferro-Sequels), contains stool softener.
One Week before Surgery
Hibiclens™ Soap: Use Hibiclens™ (over-the-counter antibacterial skin cleanser) in the shower instead of soap for 3 days prior to surgery. Apply the minimum amount of Hibiclens™ necessary to cover the skin from shoulders to thighs and wash gently. Rinse again thoroughly (be careful not to get the product on your face, eyes, or ears). You do not need a prescription for this.
Notification of Illnesses: Notify our office promptly if cold, fever, or any illness appears before surgery. Call in any allergies, medications, or conditions you may have forgotten to tell us about.
Night before Surgery
Eating and Drinking: Do not eat or drink anything after midnight the night before surgery. This includes gum, candy and water. Failure to comply with these instructions may result in cancellation or delay of your operation. If you are diabetic and take insulin you will be instructed how to take your medication and discuss this with your anesthesiologist during the preoperative visit.
Day of Surgery
Arrival at Hospital: Please be punctual. If you are running late please call ahead, but be aware that not arriving on time may cause cancellation of your surgery. Please report to the Methodist Hospital, 6565 Fannin, on the 3rd floor of the Main building, Main 3 NW. Their phone number is 713‐441‐1034.
Recovery After Surgery
POST OP INSTRUCTIONS
If you have any questions concerning your recovery, CONTACT US via email with your questions or call the office 713-441-6102.
There are 9 medications that you may be required to take after surgery:
- Antibiotic – to be continued until the drains are removed
- Pain Medication – remember this medication might make you feel groggy and constipated and cannot be mixed with alcohol
- Colace – Stool softener as needed
- Flexeril – Muscle relaxant for back discomfort or muscle spasm as needed
- Aspirin – 81mg every day for 2 weeks after surgery
- Iron – same dose as taken before the surgery
- Multi-vitamins – daily
- Zinc – supplement 50mg daily
- Selenium – recommended for wound healing
The flap(s) should always be warm and the same color as the donor site abdominal skin. Keep in mind that the breast mastectomy skin can be bruised and a different color from the flap skin. When you press gently with your finger, the flap should lighten and return to normal color within 2 to 3 seconds. If there is any change in the color, temperature, or pain notify the office immediately.
You will be discharged home with the Doppler in place, which is a tiny wire that will be removed at your first clinic visit. It will be covered with a transparent dressing which is waterproof. You may shower with this dressing.
You will also be discharged home with your drains in place. There are usually 2 drains in the abdominal area, and 2 in each operated breast. It is necessary to record total daily output for each drain. When the drain is near full, empty the contents into a measuring cup and record the amount in ml (equal to cc). You can also use the drain bulb itself that has markings to measure the output. Strip the drain tubing 3 times per day. If the drain requires emptying more than once per day, enter the DAILY TOTAL in the appropriate space on the Drain Output Record. Once your drain output is less than 25cc total per drain in 24 hours, that drain will be removed in clinic. We use silastic drains, which reduce any discomfort during removal of the drain. The small opening that will remain in the skin will seal in 24-48 hrs. This opening may have a small amount of drainage, and can be covered with dry gauze until it seals closed.
Most of the incisions have absorbable sutures that are hidden underneath the skin. Sometimes, you might feel a small knot come up in the incision area. Do not worry, this can sometimes happen and will be removed during your clinic visit. Your incisions are sealed with special fibrin glue so you do not need to apply any ointment. After 2 weeks, the glue will start to peel and you can start taking it off in the shower. Also, you may resume your skin moisturizer 4 weeks after surgery.
Your new umbilicus will have some sutures around it. There might be some drainage and moisture in that area. After your shower, use a cotton Q-tip dipped in hydrogen peroxide to clean the incision and inside of the umbilicus. After cleaning, dry the umbilicus with a Q-tip and apply dry gauze to keep this area clean and dry.
After surgery, your breast and abdominal area will feel swollen around the incisions, especially at the end of the day. This is normal and usually takes at least a month or more to resolve.
After the drains are removed, you may be fitted with a compression garment post-operatively to help with the swelling as you become more active. The garment has a zipper on the side to make it easier to put on over the abdominal incision. We have found that these garments provide support, and therefore decrease post-operative pain. The garment should be worn during the day for at least 4 weeks after surgery. You will also be fitted with a bra post-operatively in our office. This is a soft bra that does not cause compression issues on the reconstructed breast. These will need to be purchased through our office. A receipt will be given to you that you may submit to your insurance for any reimbursement. The girdle is $55.00 and the bra is $30.00.
You will be able to shower on the third postoperative day in the hospital. Baths can be resumed 1 month after surgery, and swimming 8 weeks after surgery.
When you are discharged from the hospital, you will be able to take short walks and climb stairs. For 1 week after you return home, do not raise your arm on the operated side higher than your shoulder. You may perform light chores and start taking longer walks 3 weeks after surgery. Of course, no lifting anything heavier than 5 pounds for the first month. After 6 weeks, you may gradually resume your exercise regimen and you can return to full active status 2 months after surgery. This does not include abdominal crunch exercise, which can be resumed 6 months after surgery.
We strongly recommend that you have a recliner to sleep in for the first 3-4 weeks. This allows your abdominal incision to heal without pulling, and prevents you from rolling on your side while you sleep. After transitioning back into the bed, you might find it more comfortable to sleep with your head elevated and 2 pillows under the knees to decrease the tension in your abdominal area. You should only sleep on your back, and avoid sleeping on the reconstructed breast flap(s) for at least 8 weeks.
You may start driving after you have stopped all your pain medication and your drains are removed. It is best to wait at least 2 weeks after surgery, in order to feel confident when driving.
You will be able to return back to a desk job, or light duty at 4 weeks after surgery. Be mindful that this should be gradual because you will feel tired more quickly and lack the normal reserve of energy.
Scars and Massage
After the incisions have completely healed, you can start applying pressure massage to the incisions to improve the appearance of the scars. Remember, that for the first 6 months, your scars will remain red, but with time they will turn lighter as they mature.
ABSOLUTELY NO SMOKING for 6 weeks after surgery (this includes staying out of the room with smokers).
The recovery period may be very difficult, when mood swings and emotions can be overwhelming. Contact our office for assistance in finding one of the many support groups available. We also have our own support group, the Pink Sisters, which is comprised of patients who have undergone a similar breast reconstruction procedure. They are very helpful both before and after surgery for any patients who need extra support.
A routine mammogram does not need to be performed on the reconstructed breast. However, it can be performed if requested by your oncologist or other physician. You should still perform a self-breast exam on the reconstructed breast and keep note of any changes in the scar.