Short presentation of DIEP and SIEA flaps

Abstract

The adipocutaneous tissue from the lower abdomen remains the most commonly used donor site in autologous breast reconstruction following mastectomy. There is current trend from conventional TRAM free flap toward perforator and muscle sparing flaps use. DIEP free flap preserves the rectus abdominis muscle but nevertheless demands dissection of the pedicle and thus at least some violation of the abdominal wall muscle integrity. This can in turn weaken the abdominal wall although in much smaller extent than conventional TRAM flap harvest. For this reason we always examine the presence of the superficial epigastric system first and hence start harvesting the flap in suprapubic and ingvinal region. When substantial pedicle is located (˜20%), flap is raised based on superficial system and abdominal wall is left intact. When superficial vessels are absent or not reliable we base the flap on deep epigastric vessels system as DIEP or MS TRAM. In either case there is no need for foreign material insertion to strengthen the rectus sheath defect. The flap vessels are usually anastomosed to internal mammary artery and vein. The access to recipient vessels is accomplished by removing the 3rd or 4th rib cartilage at the site of mastectomy (alternative thoracodorsal). Flap is tailored, partially de-epithelialised and positioned in the mastectomy defect. Viability of the transferred tissue is monitored continuously. The manner of how we harvest the flap from the donor area is of utmost importance for the abdominal wall integrity and of a less significant for the result of breast reconstruction per se. Advantages of harvesting various flaps from the same donor site (abdomen) will be discussed and illustrated with cases.