Surgery Spotlight: DIEP Flap Breast Reconstruction-Surgery Spotlight: DIEP Flap Breast Reconstruction

Surgery Spotlight: DIEP Flap Breast Reconstruction

Video Transcription

Hello, my name is Maurice Nahabedian and I'm a professor of plastic surgery at Georgetown University Hospital.  Today we're going to go through an operation on a woman who's had a left mastectomy, she's had radiation therapy, and she's going to have delayed breast reconstruction.  Our plan is to do a DIEP or deep flap breast reconstruction. So what we plan to see during this operation is how I dissect out the internal mammary  vessels, how I dissect out a perforator, and how we go about insetting the flap to achieve our final outcome.  So we've already drawn our initial markings, I'm just going to go ahead and re-delineate where we are going to start the operation, so here's her old mastectomy scar, this is  her inframammary fold, and what I'm going to do is I'm going to basically score that lower pole area just so I can get a little bit more of a balance between the other side.  And it looks like we'll either go for the third or fourth rib, we'll see what it looks like once we've started. Okay, I'll take a 5th, 10th blade, alright.  Okay, cautery, flap sponge, all right so we'll use the electrocautery and get through the subcutaneous fat until we see our pectoralis major muscle and you  can see she's got a generous amount of subcutaneous fat which isn't always the case especially in a radiated patient sometimes it can be quite thin but her  fat actually looks pretty healthy which is all good that's kind of a sign that maybe there won't be as much inflammation around the vessels later on  so we're starting to see hints of the pectoralis major muscle here so we'll just elevate this and then basically create recreate a mastectomy defect so  we want to make sure that we've got enough room for our flap to sit in here  Okay, now let's come over this way  So, I tend to use a lot of electrocautery just because it really speeds up the operation and we get good hemostasis and, you know, for this part I think it's really the way to go.  Okay, so we are almost, our dissection has really progressed all the way down to the level of the desired inframammary fold.  Laterally, we've dissected really towards the lateral edge of the incision and we really want to make sure that we have enough room for our flap and you can see just how thick  these mastectomy skin flaps are, so it's really kind of a nice setting for us. Let's just dry this up a little bit.  Okay, so one of the things I like to do in patients who have been radiated is sometimes this lower pole can be a little tight and not as flexible, so I like to score this fat  a little bit just to give a little bit more flexibility to the skin. She's not that tight, but in some of the radiated patients, it will be very tight, so I like  to do this maneuver. It just gives me a more natural shape if I really want to try to preserve this skin.  So you can see how it's already starting to fold a little bit easier.  Alright, so now what I'm going to do is start working a little bit more medially towards the sternum until we get to that pectoralis origin. Okay, lap sponge.  Alright, so now what I do is I really start to feel for the ribs, and I like to feel for the inner spaces. And that gives me an idea of where I want to go.  So I think up here we're at number three. Here is number four, which correlates to what I've drawn.  So I think what I'm going to do is I'm going to take out the cartilaginous portion of the fourth rib,  and then I'm going to work in that inner space and expose my internal mammary vessels. If there ever is a problem, I can always go up to the third level.  So let's just make sure that we're all completely dry. Alright, so let's go ahead.  So what I like to do is I like to just keep my fingers on the ribs so I know right where to cauterize. And again, I do all this with electrocautery up to a point.  But we'll just go through the pectoralis major muscle here until we get to the surface of that fourth rib. And it's just a linear incision here.  I like to take it to the junction of the cartilage and the bone. Now, I don't know if you can see it real clearly, but this is bone, this is cartilage.  So, I don't like to remove the bone, but I do like to remove the cartilage. So, I'm going to just put a little score mark here so you can kind of tell where that junction is.  If you remove bone, it's very painful for the patient. Now, the other thing I like to do is I like to take this all the way to that sternal cartilaginous junction.  Because you really do have to remove it all. And the way you can always tell you're at the right place is you just kind of put your finger into that space  and you can get an idea of how far you have to dissect. I also take away all these intercostal attachments on that cartilaginous portion. And you can do this various ways.  There are some instruments that you can use, but I prefer just to use cautery just because it leaves things relatively bloodless. Let me just dry that up a little bit.  Now, the other thing I like to do is just make a little back cut in this muscle.  Therefore, later on the muscle won't really scissor on itself and tend to narrow that space.  Now, let's go ahead and get a Wheat Lantern. So, now what I like to do is get a large Wheat Lantern and just separate these fibers a little bit.  It just gives us better exposure and allows us to do this a little bit more easily. So, we'll keep going up here.  So, constantly feeling so I can actually feel with my finger where that sternal cul-de-sac is above and below this rib. So now we'll free this up a little bit more.  And I usually do this on a cautery setting of about 30 or 40. It seems to work well because I can get good hemostasis and I can get through the fibers.  You don't want to go too deep with this technique because you'll hit that posterior perichondrium. I like to do that with a doyenne and you'll see how I do that in just a second.  Let me get a freer first, Alex. Now I'm just going to skeletonize this just a little bit, see if I can get a nice perichondrial edge on both sides.  We'll keep it dry. Let me get a cottery unit here.  Okay, now let me get that doyenne.  So then I take a doyenne, which is just a rib elevator essentially,  and I will go right along the edge of that perichondrium, kind of going back and forth. I try not to get any of the muscle because it'll just create a little more bleeding.  But I'm hugging the edge of that perichondrium and working my way around that posterior surface,  taking care not to get through that posterior perichondrium.  Other one. So then I use the other one and go on the other side, and I try to connect these two.  And this is all above the level of the osseous junction.  So we're in a nice plane. And there we go. Now we're through.  So then you can just kind of scrape this up and free up the cartilage from that posterior perichondrial level. And it's an avascular plane, but it will bleed if you get too close.  So then I take my rib cutter, and I get around this.  There we go. And my first cut will be just at that cartilaginous junction. Get through the rib, and then just work up a little bit.  Take out a little bit of that cartilage. And then just work up a little bit. Take out a little segment.  So now you can see that posterior perichondrium is intact. We really don't have much bleeding.  So now I'll take a freer, and I get underneath here like this.  So we continue to free this up, exposing the cartilage.  And then we'll take a ronjour.  And I like the wide-mouth ronjour because it gets around that cartilaginous segment. And I just snap it off. And we'll do this all the way to that cartilaginous sternal junction.  And you can just kind of peel this off. All right, so now what we'll do is we're going to lift that perichondrium, and then we'll be able to see our internal mammary vessels.  So let me take a 15 blade. So what I like to do here is I basically... Here's my vessels here, so I stay lateral, and I just kind of fracture this perichondrium with a scalpel.  And then what I'll use is a fine forcep to elevate this off. And it just peels right off.  And we're going to be getting on the pleura in a little bit. So you don't want to get into the pleura. You don't want to give her a pneumothorax. Let me take a Jacobson.  Okay, so now... Again, I like to do this sharply, so we'll take our cautery unit. And I'll have Lauren buzz in between me just to separate these fibers.  Okay.  Yeah, it's common to get a little bit of bleeding here, but you can easily cauterize it and keep it under control. So now we'll keep elevating here.  I know I'm in a safe zone because our internal mammary vessels are there. We will encounter some perforating branches, which we could easily clip or cauterize.  Got to be real careful here because sometimes this posterior perichondrium can be real adherent to our vessels. So you just got to just very delicately dissect and tease this off.  Now we're coming on to the internal mammary vein here as well. And the vein is very thin-walled, especially in a radiated patient,  so you have to be really careful because it's easy to traumatize and it's easy to sometimes get a small little perforation in that vein.  Okay.  So now we'll continue here.  But just so you can kind of see, this is like a small internal mammary vein and it frequently will communicate with the larger one. Here's the internal mammary artery.  Here's the primary internal mammary vein right here. So we'll continue to skeletonize this.  So now we're in a relatively safe zone because we're now medial to that vein. And you can appreciate why we had to remove all of this cartilage  because if the cartilage wasn't excised, it would be interfering with our ability to expose these vessels.  So now I'm just going to cut this posterior perichondrium out. I like to use a scalpel and just transect it right there. It's a safe zone.  I'm not worried about getting any bleeding here. So now I don't have this flap of skin, and I've got my vessels visualized.  Now you can see because it's a left-sided, we're over the heart, you'll get a lot of cardiac pulsations transmitted through this. So in this woman we decided to do a deep flap,  and really I prefer doing free tissue transfers in patients who have had mastectomies and radiation. Implant reconstruction just doesn't work well in those patients.  It's hard to stretch the skin. So I like to use their own tissues. Now I prefer the deep flap because it doesn't remove any of the muscle. We're able to take the skin and fat,  preserve the continuity of the rectus abdominis muscle, and that way they don't have as many donor site issues as they do if you were to take the entire muscle.  So women report better strength and better outcomes using that. So those are the main indications for doing it. Now the contraindications for doing a procedure like this  would be in somebody who is morbidly obese, has multiple comorbidities, isn't healthy enough to really tolerate a long operation. This operation can take anywhere from 4 to 6 hours  for a one-sided reconstruction and anywhere from 7 to 10 hours for a two-sided reconstruction. So you really need to be healthy enough to tolerate a long procedure.  All right, so now we drew our marks with the patient standing. So frequently what I'll do is I'll redraw the marks with the patient's supine,  and you can kind of see that the upper edge is maybe a little bit high, so I will lower it by about a centimeter. I like to stay right above the umbilicus,  and I will take this out again to the anterior spine, and I try to make the lines straight so everything will be nice and even.  Most of the perforators that we're going to be considering are going to be in this periumbilical area.  Now one of the things she does have is she does have this prior midline incision, so this flap will be a hemiflap. So we will eventually cut around the umbilicus.  We will split this flap down the middle, and we will use this or this for that reconstruction there, and she's going to have plenty of tissue.  Again, this lower line is just an approximation. When we've done our upper dissection, we'll sit the patient up and then see how far down we can get. I'll take a 10-blade.  Okay, so now we'll go ahead and start.  Okay, so now we're at the level of the anterior rectus sheath, so what we're going to do is  we're going to undermine now, and you'll see perforators coming through the anterior sheath into this adipocutaneous compartment.  We usually just cauterize these because this is not going to be included in our flap, obviously, so we'll undermine this a bit now.  We want to undermine to the point that we can get good excursion of this upper skin flap so we could get closure, because the goal is to have this edge come all the way  down to that inferior edge, and based on that degree of excursion, that'll determine where my inferior incision is going to be.  Okay, so I like to feel her costal margin to see where we are in relation to that, and we can still undermine a little bit more, but a lot of times you won't need to undermine  too much, so you can tell even already without having her flexed, we can really come down quite a bit. So what I'm going to do is undermine just a tad bit more.  So you can tell that the anterior skin and fat still has excellent blood supply. Okay, all right. So now we'll have anesthesia sit her up a little bit.  If you can bring the back up a little bit, please. So now we'll be able to determine exactly where our inferior incision is going to be,  and you can see that we can easily get down to where we need to go. Okay, that's good. So we have plenty of length, so we'll go ahead and lay her flat again.  We'll take our marking pen and re-delineate this mark, but I think we're going to stay right on what we've got drawn, so I'm pretty happy with this, and we'll sweep down here  a little bit, make sure we get all that, and we're going to end up dividing this here. Okay.  So one of the things you can always look for is the superficial inferior epigastric system, and the artery and vein will usually be coming off here, and it's nice to visualize those  vessels and consider using them as a backup if you need to for augmenting venous outflow if there ever is a problem with venous congestion.  Oftentimes, and even in this case, I'll point it out, but we'll probably just cauterize right through it because I'm not planning on using those vessels, but just to be aware  that the superficial system is available and you can actually base flaps off that superficial system. So we'll once again go through our dermis.  Now, because I'm going to do a hemi-flap, I'm not going to be as worried about this, but you can see here, I don't know if the camera can get this angle, but this is clearly  the superficial infrapigastric vein, and it sometimes travels away from the artery. The artery may be a little bit deeper, and it may be off to either side, but this is  the superficial infrapigastric vein right there, and again, you can use that to augment venous outflow, or you can base a flap off that.  We are not going to be using that for this hemi-flap today, so let's take that down. We are essentially at the anterior rectus sheath here, and so far everything looks good.  So now what I'm going to do is we're going to cut around the umbilicus, and we're going  to preserve the umbilicus on its stock, preserving that subdermal plexus, so the way I like to  do this is to actually grasp at the 12 o'clock and the 6 o'clock positions, hold that, and then I will just cut around it.  So we'll use our marks, and cut, okay, now we'll go to the 3 o'clock and 9 o'clock positions, forceps.  Okay, now we can take those out. Now what I'll do is I will go ahead and just cut around the umbilicus, getting through this dermis with a pair of Mayo scissors.  You could do this with cautery, but I really want to minimize the amount of thermal energy  around the umbilicus, just because it's going to be a little bit more tenuous, so I do this with a sharper technique, avoiding thermal.  If there is any bleeding, we'll achieve hemostasis.  So now, that is done. So because she's got this midline scar, I'm going to go ahead and just divide this down the middle.  I might theoretically go to the other side, but the chances of having fat necrosis or partial necrosis is increased because that subdermal plexus is violated.  So whenever I have a midline scar, I usually cut right along it. I don't consider taking any additional flap. So we'll divide this down the middle.  So now what I like to do is I like to just kind of suture this up here, just to keep it out of our way. Force it.  Okay, all right, that'll keep the flap out of our way, and then we can better dissect this.  So now we've got two hemi flaps, so we have the luxury of selecting one, and I think we'll be fine.  I typically tend to use the contralateral, but oftentimes you can use ipsilateral. With bilaterals, we'll just do ipsilateral to ipsilateral.  But oftentimes we're working on this side and working here, so we just do whichever side is going to be more convenient.  So now I'm going to start laterally here and elevate this flap.  So I've gone to this cooler bovie, now down to a setting of 20, just because we're going to be encroaching upon our perforators here.  So what I tend to do, if I don't see any perforators that I think are going to be suitable, then I tend to do what's called a muscle-sparing free tram.  And I tell patients ahead of time that we may have to do this if the quality of the perforators is inadequate.  So, we're creating our column of perforators and in a second I'm going to get the Doppler and see what I think.  These are average caliber, not tremendously large, so you have to be a little bit careful. Let's get a Doppler. There's a medium one.  So the lateral and the medial perforator actually sounds pretty good. Here's another one. I'm happier with the perforators on this side. So here we go.  Here's this lateral perforator. Here's another lateral. Here's a medial perforator. We've got another medial perforator over here.  Now one of the other things I like to do is I like to determine whether there's actually a palpable pulse in these perforators.  And there is a palpable pulse in this lateral one here.  And I do not feel a very good palpable pulse in this medial one even though there is good flow characteristics. So palpability is an important issue.  So I think what we're going to do is I'm going to base this flap right now off this lateral perforator. So we'll start our perforator dissection based on this one.  Now I'm not going to divide those other perforators until I am convinced that this flap is going to be adequately perfused on this. So we'll start off on our dissection here.  This is a backup. I can always do a muscle-sparing free tram here if this doesn't work, but I've got plenty of options.  Plus if this perforator turns out not to be adequate, I still have the other perforators that I could also choose from.  So it really boils down to patient safety and making sure that what I do is going to be successful.  I am always better safe than sorry on these flaps because sometimes if you put all your eggs in one basket, the operation can be over quite quickly, especially with these  operations. So let me first undermine this lower abdominal flap a little bit more because when we dissect this vessel out, we're going to have to come down into this area.  Because of her prior operation, there's a lot of scar tissue down here. Now what I'm going to do is I'm going to... her rectus muscle is right around in here.  So what I'm going to do is I'm going to make a little fasciotomy here.  Okay, and I'll take a Jacobson, and we will start opening up this on a, on the, let's come here. So we will split this, and I direct it a little bit laterally,  so that we can get to the point where our infaropigastric vessels are exiting lateral, on the lateral edge of the muscle.  So sometimes these perforators will come through a tendinous inscription, which I think is happening here, because I don't really see a good little slit in the  fascia. So that sometimes means there's a fibrous band around that perforator. So in those situations, what I do is I take just a small one to two millimeter cuff  of the anterior sheath around the perforator. And again, it's just a safety maneuver, so that I don't injure that perforator. Okay, let me actually borrow  that for a second. Now let's do this.  Get it to baking.  Okay, here's that again. Okay, so now we'll be able to better identify this and get underneath here.  See, we are right at, this is all fibers. There's an inscription right here. So, let's go ahead and divide that.  Now the operation would be a heck of a lot easier if I would just divide all those perforators.  And I think I might, for the purposes of visualization, because we always have the other side as a backup. So I'm fairly certain I'm going to use these two perforators.  So what I'm going to do is I'm going to clip this perforator. Let's get a hemoclip. And it'll just make the visualization of this dissection a lot more visible.  So I think you'll be able to really appreciate it. So we'll take this down. Let's get a scissor.  Okay. Let's take this down. Let's take this down. Let's get another clip here. So now we're going to clip this perforator here as well. So now we will be on two perforators.  And I am fairly confident that these are going to work just fine.  Let's take this down. Let's get another clip. All right.  Okay, so now, now you can look at the color of the flap and it still looks still looks fine and you can assess bleeding from the edges.  and we're still fine. It's still bleeding at the edges, so we know that what we've got on these two perforators for this hemiflap should be just fine.  You can see how it's bleeding all the way here at the distal edge, so, and it's always at the subdermal plexus that you really want to assess. So you can see  it's bleeding nicely. There doesn't appear to be dark purple blood signifying congestion. It's well perfused, flap is warm, and it's got good color. So  now the dissection of the perforators begins, and it's interesting because you can almost see kind of a crossover branch between these two perforators, so  they are linked. Now let me take a Doppler. Let me just kind of listen to what our perforators sound like.  Sounds great. Sounds great. So we've got two perforators. Let's see if we can hear anything on the skin paddle. I don't know where these are gonna be, but, and there's  a nice signal on the skin. So I think we're okay here. So now let's start our perforator dissection. Okay, so let me take a small wheat liner. In fact,  actually, let me hold off. Let me take the DeBakey and this. So now we'll start off by just making a little myotomy. I can't, because of this inscription, I  can't gently tease this muscle away, so I'm gonna have to basically just superficially go through this here like this. So we'll start a myotomy out here,  and I also like to make sure she's completely paralyzed at this point. Is she paralyzed? The anesthesia?  No twitches?  So we'll just go through this until I can better define where that infrapigastric is going. And again, a lot of times I won't have to cut this way into the muscle,  but because of this inscription here, we're going to have to cut a little bit of this muscle.  So we've really started dissecting out the perforator, but I want to approach it now from a little bit of a different angle just because there's a lot of dense tissue along there.  So I want to look at the lateral border of the rectus muscle here.  So over here, the infaropigastric artery is going to be making itself visible off this lateral edge. And then what I can do is I can work in a retrograde fashion  and see what direction it's going in. And that might facilitate the dissection of that perforator.  So there's our infrapigastric vein, and the artery is just going to be off to the medial side of that.  I'll take this down a little bit more.  So there's our artery and vein right there. Now, there will be some of these lateral intercostal vessels and nerves that are going to be coming into the muscle here,  so you try to do everything you can to preserve those nerves so that there will be some muscle function at the end of this operation.  There will also be plenty of branches that you'll see here, which we'll go ahead and divide. So let's get a small clip.  Alex, if you could just kind of pull that back.  Alex, if you could pull that back. Just that one, yeah.  And there are a million and one uses for a BOVI, and one of them is a vessel retractor.  Okay. Okay.  All right, so you can kind of get an idea of how this main source vessel is coming up this way and feeding these perforators.  So now, and most of this is submuscular, but obviously there's a portion of these perforators that's intramuscular, so we'll have to dissect out that intramuscular portion.  Now, the other thing I'm going to do here is I'm going to free this up a little bit more superiorly as well  and get underneath that and preserve those nerves.  So here's a neurovascular bundle.  And she's got a very thick rectus abdominis muscle and very active rectus abdominis muscle.  Okay, so now, so here's one of those nerves going into the muscle there, and then this intercostal artery and vein will eventually probably just divide.  And here's another branch going into that, and we will divide. It'll just facilitate her dissection. So, but let's go back up here now.  All right, so let's take this little sponge.  Let's take our Wheat Lantern.  And let's retract this and see where we can go now.  Jacobson.  Okay, so let's take these bands of muscle down here.  There's really no way around it. I have to take a few muscle fibers with this flap  because of these inscriptions and proximity of the perforators to one another.  Okay, so we're clearly making progress because I can actually see now the deep system vein along this medial edge. So now we have to connect these here.  So I have to take down these intervening muscle bands.  So we're under the muscle here now, and the main source vessels are just going to be a little bit more towards that medial edge.  So we'll just continue to work around this circumferentially and get through this other additional layer of muscle, which we just have to do.  There is just no way to dissect out this perforator without taking a small cuff of muscle.  So here's the superior extension of the deep system, going cephalad. The inferior extension, which is what we'll continue to dissect out, is over here in this bundle.  There's still a little bit of fatty tissue around it, but we are soon going to skeletonize it.  Let's take a Doppler. Let's just listen to our perforators while we're at this juncture. So that still sounds good.  So somewhere along the course of this dissection, we lost our inflow to this one perforator. We're still in good shape because we've got two.  It's probably something that was in an inscription.  At this point, let's hold that there. I'm going to make a small extension in this myotomy. Actually, let me do this. Let me elevate this up here and off.  It may be that there's some spasm of that perforator that's down there, so we'll see. It may come back.  So you can really see how this dissection is progressing now because we are on our primary perforator and source vessel.  All right, so now what I'm going to do is to just make sure that we have good flow through our perforator. Let me take a single Ackland clamp, a large one.  I am going to clude this flow superiorly.  So now I'm basically ensuring that all the flow to this flap is coming from the inferior system and not through the superior system. So let's take the Doppler again.  And we have a great signal.  All right, so now I know that we can safely divide this. So let's take a medium HEMA clip.  Let's take a Jacobson.  So now we're going to clip this superior extension. And that will allow me to kind of manipulate the flap a little bit so that we can facilitate our dissection.  This was a little bit more challenging than usual because of this tenderness inscription.  But we're, I think, in good shape now.  So we're on our pedicle here.  And you can see the vein here and you can see the arteries right adjacent to it, right there. There's a little bit of intervening tissue.  And we're really in the submuscular plane here now.  Theoretically, I don't really have to create any more of a myotomy. I may just do this dissection all from the posterior aspect. So let's do this. Let's take this out.  And now what I'll do is we will get an Army-Navy. And let's do this. Let's get the long end.  And do that. So now we're going to have to divide some of this.  Let me just check one thing here. Let me make sure that our...  One of the things that you have to be wary of is when you do a lateral perforator dissection there is a little bit more involvement of the intercostal nerves.  So there have been some studies that have shown that muscle function can be a little bit more compromised with lateral perforator dissections compared to medial.  But in her case the dominant perforators were lateral and that's why we're doing this. But we are progressing nicely now. We are on our perforator. It's almost freed.  Now there's the major split in the infrapigastric that we're seeing now. And once this has been divided then we will be home free.  All freed up. We are on our perforator. We've preserved this nerve going into that muscle. This is all free all the way down towards the edge. So let's get our Doppler.  Let's just listen. Make sure we're okay. So we've got a good signal. I'm going to check that other one and see if that's.  I think we probably had a little spasm but we've got a little bit of a signal on that second perforator. So I'm okay with that.  So now the last thing we have to do is we have to free up this infrapigastric down below. And then we will be ready to start our microsurgery. So let's go ahead and hold that.  Let's get a Army Navy.  So just dividing some of these small branches off the deep system as it's coming off the iliacs.  I like to take this close to the iliacs because that gives me large caliber vessels  and that just facilitates the microsurgery. I like to  sew two and a half millimeter vessels to two and a half millimeter vessels. It just makes for  a smoother procedure.  All right, that dissection is finished.  So we've got a flap that looks good and we will leave this attached  until we're all done and we know we're in good shape. All right,  maybe I'll do it this way up here.  Much better. See that? That's perfect. All right, so that gives us good exposure. We can see our  internal mammary vessels. Thin skin's not in the way and that'll really facilitate doing the  microsurgery. And there's our vessels with the heart pulsating underneath. So we'll have a nice  challenging anastomosis. So because she's been radiated, she does have a little bit more  perivascular fibrosis. It's a little bit more indurated here. Normally this teases off fairly easily.  Now typically I prefer to use the medial vein and I still may because this may be a little side branch here but we may use the lateral vein too and these eventually come together  so if I was to go up a little bit more we could get additional length.  She's a little fibrotic here.  I think I might actually take this up a little bit.  Let me take a Jacobson and a Raytech and we'll get a low set cautery.  What I'm going to do is just give me a little bit more cephalad exposure so we'll  Okay, a micro scissor.  So now you can see that our internal mammary artery is partially skeletonized but what I'll do is when we're getting ready to do our anastomosis I'll  skeletonize it a little bit more. So here's our artery, here's our medial vein, here's our lateral vein. I'm gonna hook into the lateral vein because this  medial vein is a little bit sensitive. There's a lot of scar tissue around it and it's very thin-walled so I don't want to risk traumatizing. So we'll do a  lateral anastomosis. It should work out just fine. So now we're gonna go get our flap. All right so we are right now on our inferior pegastrics. I don't know I  think you can probably see where we are right here. So here's the pulsating artery. So what we'll do is we'll first clip the artery and slide down. That's  good. And then we will clip the big vein which is right here.  All right, and then there's that small small vein which we can clip higher. Okay now we'll take the micro scissor. So now we'll divide these vessels and then  we'll be able to remove our flap.  Okay so now we're all freed up and voila here is our pedicle with a little remnant of muscle but this is still in my mind a DIP flap just because it's  really just around a tendinous inscription and it's really miniscule amount of muscle that we've removed. So you can kind of see our vessels here and  then we'll take it under the scope and further skeletonize those vessels. So now well the other thing I like to do is let it let the blood kind of drain out of  the flap a little bit and then we'll just put it right up here. Okay all right now what I do is I'll re-drape I'll let the pedicle kind of untwist itself and  then just kind of re-drape it here. Make sure we've got enough length so and that'll be okay and then we'll suture the flap to the chest wall. So let's get  some suture. Actually it's a little go ahead that's um yeah like there to there.  So this is just to stabilize the flap so it doesn't really move it's just a common technique but I think it's necessary. Now the arteries are obviously  very thick walled and relatively rigid whereas the vein is a little bit more flimsy but usually of larger caliber. So we can skeletonize this a little bit and  that looks pretty good. Now our arteries a little longer than our vein so I'm going to just trim this artery a little bit right here.  Because I'm going to use the I like to suture the more medial structures first so I'm going to do the arterial anastomosis first followed by the venous  anastomosis. Okay so now let's take a right angle and a medium hemoclip. So we're going to clip the more caudal end of the artery.  Right about there, I think.  Towards that clip. Don't pull up so hard. That's good, right there.  Okay, I'll take a double Ackland clamp.  And we'll take our visibility background. So now we'll put on our Ackland clamp. Right about here.  And then I'll align this, we'll hook up this artery.  Up like this.  And we'll put our visibility background, just because it makes it a little easier to see everything instead of operating in a sea of red.  Alright, so now you can see our vessels. I always like to divide the artery after I've got everything lined up.  It just makes it a lot easier, that way you don't lose control of the vessel, and things tend to go a little bit smoother.  Okay, so I'm going to divide this now, right about here. It's going to retract a little bit, so you can see I leave a little bit of an uneven mismatch.  Once we cut it, then it lines up.  There we go, and I'll get a little bit more of this off now.  A little more adventitial stripping here, give us a nice clean edge to sew to,  and I think we're going to be in good shape. All right, dilator, so now I like to dilate the vessels a little bit and irrigate them with some heparinized saline.  All right, that looks good, and we'll do the same thing here.  There was a little something in there.  Okay.  A little suction micro, and I'll take an 8-0. I like to use 8-0 nylons. You can use 9-0, but 8-0 works for these. And let me just see if I can focus that a little bit better.  And I like to hand sew all my anastomoses.  Some people like to couple veins. Some people will even couple arteries, but I tend to just hand sew everything. And I like to start by just doing 180-degree sutures  and then just interrupt it on the front wall, then the back wall.  Got a little bit of motion, obviously, because of the heartbeat, but it's just what you have to do sometimes with left-sided reconstructions.  Okay, now, and again, my preference is to hand sew. Most microsurgeons I recognize like the coupler, which is fine. I mean, it's probably a little faster,  but I guess I'm kind of a creature of habit. I've always done it this way, and it's worked out fine. So I continue to hand sew.  Alright so the anastomosis is finished. Now what I'm going to do is take down, open up this vein so we'll release the clamp. There's a little branch right there, a little right  there. Let me take an 8-0, there's a little tiny...  That's better, okay, so now we're gonna open up there, and we got a vein that's not leaking.  So now we'll open up this artery, and we'll really see how things are going.  And now we have flow.  So now we've got, let me just blot this.  Let's get a micro-hemoclip.  So now let's look to see this little venous branch, see if anything comes out of here.  And there we go, we got some bleeding coming out.  So we know we've got circulation, so now I will clip that.  And we'll take our Doppler. And there's our...  Yep, so we're in good shape.  Okay.  We got an artery and a vein.  Okay, so we're good, everything looks good, nice and dry. So let's take out this, all of our instruments are out.  So now we can start insetting and closing.  Okay, so now what we'll do is we will put this in here.  Like this.  And now we have our breast. And you always gotta make sure that your pedicle  is re-draped properly in here. So...  Ah.  And that's how we want it.  Okay, now can you sit her up, bring her back up?  So now what I like to do is sit her up a little bit  and see how this flap is going to re-drape and fall and kind of balance with the other side. And you can see we've got good color and it's bleeding nicely.  It's warm, yeah, up more, like 40 degrees.  Okay, let me take it out some brown and stapler.  Okay, that's good.  So now we'll kind of move this medial.  All right, let me take a marking pen. So what we'll do is we are going to de-epithelialize  this portion, the buried portion of the flap.  Okay, so this will all be externalized.  Then we'll remove the skin from all the buried portion. So let's go ahead and lay her flat.  We're just gonna remove the epidermis and leave a layer of dermis behind.  And you can see that it's bleeding nicely because this is a well vascularized flap at this point.  Okay now we'll go ahead and do this. Let's get some irrigation. Let's wash this out.  All right, now we'll go ahead and put this in here. So now we're ready to really close this up and we'll just go skin edge to skin edge and that'll actually fit in  there nicely now and then we can take those out. Let's take these staples out. Now I'm gonna put the drain in in a second but let's you know we could do is  look at the abdomen here. So we've made our fasciotomy, we've made our myotomy the muscle is still completely in continuity. That lateral innervation is  preserved going into the muscle here. There's enough residual blood supply that this will do fine. What we'll do is we'll just put this muscle to that  muscle and then we'll close the anterior rectus sheath and then after that we'll just go ahead and close up the skin. We're essentially almost  finished. At least the major portions of the operation are done. So now I'll put a drain in here. So let's get a 15 blade. So we'll just make a little incision here. Tonsil.  Let me just open that up a little bit more. Okay, and there we go. I like to use these Blake drains. They slide out really easily.  They're not really painful for the patients in the office when we do take them out. Then I usually place my drain kind of in a pattern like this.  I don't like the drain to go anywhere near the anastomosis. And this is really just to remove any additional fluid that's probably going to accumulate.  These drains will stay in for anywhere from five to seven days. And then that'll be it. Then I suture the drain in, 3-0.  So the first thing I like to do is whenever there's a myotomy, I always put a stitch or two in the muscle just to kind of re-approximate the two edges.  So that way those nerves, as they neurotize, will go into that adjacent muscle.  Scissor? That's pretty funny. So we'll kind of contour this a little bit.  Okay, now we'll go ahead and close that anterior rectus sheath. I like to use a xeroproline, or is this a PDS proline? Yeah, xeroproline, and we kind of line  this up. Alex, can you please just retract that a little bit?  Try to get both layers of that anterior rectus sheath just so we can get a nice solid repair.  And I'll take, we'll take the drains, so we'll place two drains now, and we'll stay right about this level.  Okay.  And the other.  3-0 nylon. So this is the bioptics probe. And this is actually the monitoring device. So this just gives us kind of a transcutaneous oxygen reading on the flap and gives us an  idea of where our baseline tissue perfusion is in terms of oxygenation. Okay. So basically, we look at it in a couple of ways.  We really want to make sure our signal quality is high, at least 90%. And then we look at the transcutaneous oxygens.  So we got a tissue oxygenation of 74% now with a 99% signal quality, and you can see the tracing start to go. So this will obtain a steady state.  We'll be up on the ward, and the nurses can monitor this. There's alarms if it drops, and it just gives us a good indicator that our tissue perfusion  is really good and everything is working nicely in terms of the anastomosis and perfusion. So a nice little toy that we use to monitor these flaps. But that really is it.  Operation's finished. So we just go ahead and put on our bandages at this point, and we can just do that.  So the recovery period following a deep flap is actually not terribly complex. We'll monitor the flaps frequently. So right now, the patient will be in the recovery room.  The nurses will look at the flap every 15 minutes. We've got a bioptics probe on the flap that's telling us what our transcutaneous oxygen saturation is. So that's very sensitive.  If there's a dip, then we know that there may be a problem, and we have to go back to the operating room.  That with a Doppler signal that may be abnormal is confirmation that we need to go back to the operating room. If everything goes well, she'll be transferred up to the ward.  The nurses will look at the flap every hour for the first 24 hours, and then we go to an every four-hour monitoring.  We leave the bioptics on for two days, and if everything goes well, she's able to go home on post-operative day three. We get them ambulating post-operative day one.  We start them on a diet post-operative day one. We start them on aspirin post-operative day one, and really start to get them up and moving.  Ninety-five percent of the time, the patients go home on the third day, which is a big plus because they can start to get back into their normal routine.  And after about four to six weeks, I tell them they've got no restrictions. They can pretty much do whatever they want.  They can go skiing, play tennis, whatever, and they can do their sit-ups and crunches because we didn't take any of the muscle.  So we've just finished our delayed breast reconstruction using a deep flap on this patient who presented for this procedure.  Now there are a couple of teaching points that I think are important to reiterate. The first deals with the exposure of the recipient vessels. The internal mammary were selected.  Now keep in mind that they were previously radiated. So what we saw was that there was a little bit more perivascular fibrosis.  We started off the dissection under loop magnification, and it was a little bit more of a difficult dissection.  So we really weren't able to fully dissect out these vessels until we were under the operating microscope. So that's one of the teaching points that I wanted to go over.  The second was that this woman had had previous abdominal surgery. She'd had a midline incision. We started on the contralateral flap, which was the right side.  During that flap elevation, I noticed that there were some small perforators. I wasn't real happy with them.  So fortunately, we were able to look at the other side to see if there was a more dominant perforator, and there was.  We actually found about four or five perforators, but there were two in the lateral row. Now they were close to one another, and they were coming through a tendinous inscription.  So sometimes when you're doing deep flaps and those perforators are coming through a tendinous inscription, you have to be a little careful.  You're going to have to take some fibers of muscle in order to avoid injuring the perforator. The other thing to keep in mind is this was a lateral row dissection, and we know from  the literature and some of the anatomic studies that the neural structures are more intimately associated with these lateral row vessels.  When we were doing our dissection, we did have to cut through some of those motor branches, and we did notice a couple of little twitches of the muscle.  So keep that in mind as well when you're doing a lateral row dissection. I think for the most part, though, the rest of the operation was fairly straightforward.  We inset the flap the way we would typically do. On a delayed reconstruction, the space is tighter. You don't have to do a lot of internal suturing.  As far as the closure goes, we closed using our zero-prolines in a figure-of-eight fashion. We did our three-layer closure. I like using drains.  We used bio-patches over the drain sites, and I used Steristrip® Xeriform® and a dry occlusive dressing for our incisions.

Video Summary

In the video, Maurice Nahabedian, a plastic surgeon at Georgetown University Hospital, conducts a delayed breast reconstruction for a patient who had a left mastectomy and radiation therapy. The procedure is a DIEP (deep inferior epigastric perforator) flap reconstruction, which is detailed step-by-step. The operation involves dissecting the internal mammary vessels, identifying and preserving perforator vessels, and insetting the flap for the final outcome. The surgeon starts by marking the surgical area and using electrocautery to achieve hemostasis. Emphasizing the technique's importance in irradiated patients, he highlights the ease provided by healthy subcutaneous fat, which indicates less inflammation risk around the vessels.<br /><br />Nahabedian discusses the handling of internal mammary vessels and the challenges posed by radiation-induced fibrosis. The procedure underscores careful identification and management of perforators, demonstrating approaches to vessel dissection when they traverse muscle or a tendinous inscription. He also explains the implications of choosing lateral or medial perforators based on their vascular and neural proximity.<br /><br />Attention is given to safely dissecting and using perforator stems while minimizing muscle damage, stressing how preserving muscle function is crucial for patient recovery. Despite complexities like prior midline surgeries, the procedure achieves successful flap perfusion and shaping for aesthetic balance.<br /><br />Postoperative care includes monitoring, with an emphasis on mobilizing the patient early to facilitate recovery. Nahabedian concludes with observations about the technique's effectiveness, discussing potential anatomical challenges and solutions for successful outcomes in flap breast reconstruction.

Asset Caption

In this video, Maurice Nahabedian, MD performs a delayed left breast reconstruction using a deep inferior epigastric perforator (DIEP) flap reconstruction on a 43-year-old woman who has had prior radiation therapy. DIEP flaps are frequently chosen for autologous reconstruction because they can be harvested with no muscle and minimal fascial sacrifice. In this video, observe how Dr. Nahabedian marks the surgical site and begins his dissection. Once the internal mammary artery and vein are exposed, and the DIEP flap has been elevated watch Dr. Nahabedian's microsurgery technique as the new breast is reconstructed.

Surgeon Maurice Nahabedian, MD

Disclosure Dr. Nahabedian is a speaker for LifeCell Corporation/KCI. Dr. Shestak has nothing to disclose. Dr. Aly is a consultant, speaker and advisor for Ethicon/J&J; receives research support from Ethicon/J&J; is an advisor for Angiotech Pharamceuticals; is an advisor for and a shareholder with Incisive Surgical Inc.; and receives royalties from QMP. All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Breast

Maurice Nahabedian MD; Memben

Maurice Nahabedian

Georgetown University Hospital

delayed breast reconstruction

left mastectomy

radiation therapy

DIEP flap

internal mammary vessels

perforator vessels

electrocautery

radiation-induced fibrosis

muscle preservation

postoperative care