The Deep Inferior Epigastric Perforator flap (DIEP flap) replaces the skin and soft tissue removed at mastectomy with tissue that is borrowed from the abdomen. A slim incision along the bikini line is made, much like that used for a tummy tuck. With a DIEP flap the skin, soft tissue, and very small blood vessels required to produce the breast reconstruction are removed from the abdomen. These small blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope. Unlike conventional TRAM (Transverse Rectus Abdominis Muscle) flap reconstructions, the use of the perforator flap technique allows the collection of the required tissue without sacrifice the underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is a favorable donor site for many woman, since excess fat and skin are often found in this area. In addition to reconstructing the breast, the contour of the abdomen is often improved, much like a tummy tuck.

Like the DIEP flap, the Superficial Inferior Epigastric Artery (SIEA flap) flap replaces the skin and soft tissue removed at mastectomy with tissue from the abdomen. In a select group of women the blood vessels just under the skin are used as feeding vessels for the abdominal skin and fat. The use of these superficial vessels allows the surgeon to completely avoid the abdominal muscles because the blood vessel used do not travel within the muscle. The vessel supplying the lower abdominal tissue are preserved and the transferred skin and fat are transformed into a new breast mound. The procedure is otherwise the same as the DIEP flap, resulting in a low abdominal incision much like a tummy tuck.

The Transverse Rectus Abdominis (TRAM) Flap is similar in design to both the DIEP and the SIEA flaps. In contrast to the other two flaps, in some situations a portion of the rectus muscle must be taken with the abdominal skin and fat. The decision to remove some muscle is based solely on the anatomy of the patient. Preoperative imaging helps to determine if this will be required, but ultimately the decision is often made in the operating room. The TRAM flap offers similar results in the breast but does sacrifice some muscle to obtain that result. In Dr. Haddock’s practice it is very rare that he has to use a TRAM flap as he almost always can use a DIEP or SIEA flap. If a TRAM is used then the abdominal contour is still similar to a tummy tuck.

Double flaps or stacked flaps is when two flaps are used for one breast. The most common variant of this is a Double DIEP flaps in which both sides of the abdomen are used for one breast reconstruction. This is commonly used in the setting of delayed reconstruction and/or following radiation. The two flaps together can provide more skin and volume to allow total breast reconstruction.

Dr. Haddock and his partner have one of the largest published experiences with these types of procedures in the world. They have presented on this in local, regional, national and international meetings.

The 4 flap breast reconstruction refers to bilateral DIEP flaps and bilateral PAP flaps performed at the same time. This is a unique operation that is only employed in specific situations. In a subset of patients the abdomen or thigh alone will not provide enough tissue for total breast reconstruction. By using both the abdomen and the thighs as is done in the 4 flap breast reconstruction we can obtain adequate skin and volume to perform total breast reconstruction. In these complex situations using only one location would compromise the final aesthetic result. The use of multiple flaps avoids this compromise to the breast. Additionally it allows a more conservative surgery at the donor site ultimately limiting the morbidity of the thighs and abdomen.

Dr. Haddock and his partners have the largest series of these procedures in the world.

Dr. Haddock has extensive experience with the DIEP Flap. He has performed hundreds of these procedures with very high success rates. Dr. Haddock has performed over 3,000 breast reconstructions with flaps. His approach is focused on a few key goals including superior aesthetic results, limited abdominal morbidity, and operative efficiency leading to quicker recovery. When choosing a surgeon to perform this operation experience is key. Additionally, the focus of the operation can vary among surgeons. Dr. Haddock does not simply view success as flap survival but his goal is to achieve the result his patients desire.

Dr. Haddock typically performs these operations at UT Southwestern Clemens University Hospital in Dallas, Texas. Here he uses an Enhanced Recovery After Surgery (ERAS) Protocol to provide for faster recovery and limit postoperative discomfort.

As in all procedures, there are complications associated with autologous breast reconstruction. The potential adverse outcomes of autologous tissue breast reconstruction are total flap failure or partial flap failure. Total flap failure, the most feared complication, typically occurs due to a venous or arterial thrombosis of the vessels supplying the flap. With improved operative technique, in experienced hands this risk is extremely low. Patients may also experience hematomas, seromas and wound healing problems at the donor site or the recipient site.