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Microsurgery

DIEP Flap Procedure

Authors: Rami Mossad Ibrahim, Magnus Obinah, Magnus Balslev Avnstorp MD, Peter Stemann and Birgitte Jul Kiil

Procedure (Photos)

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Step 1: Pre-operative drawing

Pre-operative drawing of donor site with two large periumbilical arterial perforators (a DIEP flap) and recipient site (internal mammary artery of left breast)

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Step 2: Harvesting of perforator flap

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Step 3: Microsurgical anastomosis

Microsurgical anastomosis of vessels on recipient site using clips

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Step 4: Closure of abdominal donor site/defect.

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Step 5: Suturing of DIEP flap to the left breast

Suturing of DIEP flap to the left breast (recipient site) – The reconstructed breast

Instruction to the patient

Pre-operative regimen

Post-operative calm regime.

Follow-up 

Clinical flap assessment by laser and/or hand ultrasound doppler every hour the first 24 hours and the following days.

See:  **LINK TO CHAPTER ON MONITORING MICROSURGERY FLAPS**

Depending on the complexity of the flap the monitoring may be less extensive.

Pearls and Pitfalls when performing perforator flaps

Pearls

  • Overall use Diligence (careful and persistent work) and intelligence.
  • Use appropriate imaging technology if possible.
  • Make sure that you have a recipient vessel in mind when planning a free perforator flap.
  • Have a Plan A, Plan B, Plan C if the vessel is no good.
  • Be aware and respectful that harvesting a perforator flap is difficult.
  • Remember that small perforator flap vessels can be anastomosed to other small perforator vessel as recipient vessels, which can be useful on legs etc.
  • Practice using magnifying glasses (loup glasses).
  • In case you have a small defect ie on a leg following cancer resection, then practice looking for a perforator flap nearby. Try to do a propeller flap instead of a random flap or a skin transplant.
  • Minor perforator flaps are also very useful in the face.
  • Look after perforator vessels near the defect with ultra sound before the resection.

Pitfalls

  • The perforator vessels are often very small and fragile. Be careful and have fun!

References

  1. Koshima I, Soeda S. Inferior epigastric artery skin flaps without abdominis muscle 1989:645–8.
  2. Blondeel PN, Van Landuyt KH, Monstrey SJ et al. “the ”gent“ consensus on perforator flap terminology: preliminary definitions”. plast. reconstr. surg. 112 (5): 1378–83; quiz 1383, 1516; discussion 1384–7. 2003.
  3. Color Doppler ultrasonography targeted reconstruction using pedicled perforator flaps—a systematic review and meta- analysis- Rami Mossad Ibrahim, Gudjon Gunnarson, Javed Akram, Jørn Bo Thomsen and Jens Ahm Sørensen.

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