DIEP 2011

Before I went into surgery in March, I was warned by my PS that he may have to take muscle surrounding the blood vessels for the DIEp.  It would show up as a "TRAM" on my post-op report, but it is nowhere NEAR a true TRAM.  The muscle taken is very small and there is very little difference between a DIEP without muscle and taking a bit of muscle to protect the vessel.  I ended up not having to use any muscle, but it wouldn't have made any difference to me if he had to take muscle.  

As for everyone who is feeling abdominal tightness, I STILL feel abdominal tightness when I arch my back and I'm 8 months out.  It is not painful, just apparent. 

Well...let's take a look at a study that examined exactly what we are talking about.  Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/15692347

The study is called Breast Reconstruction with the DIEP Flap or the Muscle-Sparing (MS-2) Free TRAM Flap: Is There a Difference?

Here is the abstract:

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Abstract

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome.

The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months).

For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction.

For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction.

These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.

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So, my take on this study is that yes, there are differences: a DIEP provides an extra margin of recovery advantage. But if a woman's anatomy does not support DIEP, taking the muscle-sparing free flap route does not necessarily mean a lifetime sacrifice of abdominal function. Getting a DIEP does not guarantee we do not have some limitations or risks.

I completely agree with Snobird that it's really important to understand the alternatives being presented by a PS, so we can make a knowledgeable choice. My PS and I sat down and discussed this and some other similar studies he had in the office (this is the only one I have a copy of). Our plan of attack was to go for a true DIEP, but he knew from my CT scan that taking muscle was a possible outcome. We discussed the relationship between portion of muscle taken, if needed, and size of reconstructed breast; I then made the choice that if he found during surgery that taking muscle would significantly enhance the viablity of my flap(s) --by assuring perfusion, or blood supply to the transplanted tissue --he would take a very small amount, and construct correspondingly smaller breasts. We talked about my 'kayak test' -- it was and is vitally important to me that I be able to get in and out of a kayak --which in my experience recruits major abdominal strength, especially when the front end of the yak is beached uphill, or when entering/exiting from our dock. I woke up from surgery to learn that he did indeed take some muscle for each of my reconstructed breasts, dime-sized, he told me.  I have lovely B+ breasts that I am fully happy with.

I suspect that the biggest real-life difference between the MS-2 free TRAM and the DIEP flaps is the time to full abdominal recovery.  My PS does mostly DIEPs (his words, plus I know three of his patients, and all had true DIEPs, so anecdotally, others' experiences do seem to support his statement that using muscle is the exception for him). I know that he gives green light to his DIEP patients to begin abdominal conditioning well before he authorizes ab work for patients getting the muscle-sparing free TRAM surgery.  I have been cautioned to wait at least 8 months before doing any sit-ups, crunches, or other specific ab conditioning work, and that having more patience--waiting even longer--is better. 

I am currently 4 months post-surgery, and I can tell you that I do still get some very minor and painless muscle spasms in my lower abs when I engage in any aerobic activity; I would be curious to know if those of you who had true DIEP have the same experience.  My PS tells me it is a common outcome of both surgeries and goes away after time.

I have zero functional limitations today: no issues in any daily-life activities. I am back to my pre-surgical cardio fitness; I have never been a runner, but I am able to do elliptical machine or DVD-led aerobic workouts (I love Leslie Sansone workouts) for 90 minutes, paying attention to heart-rate, etc.  My PS has said he would not want me to be running yet (had I any interest), but not because of muscle healing, rather because of the impact on the abdominal wall that is cut regardless of which type of autologous tissue transfer reconstruction we have.  Similarly, although I have green light to return to strength training now, he does not want me to do weighty shoulder presses or any other move that puts weighted stress on the abdominal wall. In his words, it's not the rectus muscle we're protecting at this point, but the fascia and other elements of the ab wall that need more time to heal.  Scar tissue regardless of where on the body is never as strong as the orginal tissue, and the remodeling phase of wound healing continues for about a year--and this applies to the older pedicled TRAM surgery, the MS-free tram, the DIEP, etc.

I think my PS is also simply more conservative than some others in his assessment of how long to take healing precautions, and I am A-OK with that.  I am very pleased with my outcome, and I trust his judgment that once in the OR, visually inspecting the available blood vessels, he made the best decision taking my needs to heart. I don't know that I would feel this way had he and I not discussed the research--I gave him a fully informed green light to take muscle if he felt that would ensure the survival of my flaps. 

Would I have preferred a DIEP, for that extra margin of ab-use safety?  Of course!  Am I sorry that I didn't get a DIEP, or do I think my surgeon was not competent enough to give me one?  No way!

Snobird, where are you kayaking?  I'm on rivers, can hop in right from the house. It's my favorite water activity.

Everyone: For those facing surgery and surgeon choices, why not chime in and comment on how you feel in activities that require significant abdominal use, telling us whether you had MS-free TRAM or a DIEP, and how far out from surgery you are.

Carol

Snobird, are you using topical Arnica, and if so, where did you find it?  Thanks--Carol

Carol I was taking arnica orally prior to surgery and I'm still taking it. I won't use topical arnica until al my incisions heal up. I was able to get both at my local drugstore. I just asked the pharmacist. It was located near the pain relievers and arthritis medications. You can also get it at most health food stores in the pharmacy sections.

I started oral Arnica two days before surgery and have continued.. I also am holding off on topical Arnica till I am more healed... I bought mine at GNC.

As for FREE TRAM v DIEP differences, I think they are very similar, but they are not the same, so when someone says they had DIEP when in fact they had FREE TRAM, I think it can cause confusion in some cases...there can be differences in recovery and ultimate ab strength. For example, if someone has FREE TRAM and is on the DIEP thread and complains of ab weakness, it can be misleading, implying ab strength is a side effect of DIEP. There is nothing wrong with having the Free TRAM if that is what they have chosen, but it is important to be precise so as not to confuse readers... my 2 cents.

Just V... I am very happy that you are pleased with your results... My best to you and hope that you never experience any ab issues... and please don't think I am or have tried to single you out... I just was hoping for clarification between the two procedures, so readers know the difference.

Cookie monster, I had my sx at UPenn, and the same exact thing was explained to me. I am not sure if my PS had to use a little muscle or not, I will ask at my next appointment. But I will say, my abdominal outcome is beautiful. Everyone has told me that. I am active, I am sure not as active as some here, but since my sx on Aug. 17, I can do everything I could do before. And nothing needs to be done with my abdominal area in stage 2. There are no dog ears or anything that needs to be fixed or lipoed further. I trusted her and had no qualms letting her use her judgement as to whether or not she needed to remove a small piece of muscle. If she did, I know it wasn't for the purpose of making the sx easier for her to perform, but to give me the best chance of the best outcome in her best judgment. That was good enough for me. Am going back on Dec 2 and will let everyone know if she did DIEP or free muscle sparing tram. I do think arguing over it is creating unnecessary friction on the thread.

I just found out about the Arnica and would like to try it. No problems yet, but I'd like to maximize the healing and minimize any problems or discoloration.

It's been 11 days since mysurgery, but why not start with the oral? When does one use the cream? I used Nexcare (I think that was the name) bandages on my lumpectomy scar, and it healed well, btw.

thanks to all for your input,

mgm

hi

Im trying to do some research on DIEP and look at pictures of post surgery. Does any of you ladies have a website/blog which shows pictures of pre and post DIEP at different stages? I want to see what im getting myself into.

Hi everyone,  Im new, in fact this is my very first posting.  Im having DIEP surgery Dec.19th. Merry Christmas to me :-)  I have learned so much from everyone here.  Just wanted to thank you all for the priceless information.

Vicky

I live in Washington state, and Dr Alfonso Oliva is doing the good deed. We dont have very many qualified dr's around here to choose from, but ive heard he is really good. I met him once back in July when we made the Diep appt. and feel comfortable with him.  He has this Italian accent that I fell in LOVE with!!!!!  (I think that is why i choose him lol).

I have been lurking (as you say it) on these websites for about a month now.  I have learned so much.  I didnt have a clue what a diep really was.  I didnt know there were stages of it...the nipple tatooing..I meet with my PS the 14th and I have sooo many questions for him.  Funny thing is I pretty much know the answers, im just going to let him know ive been doing my research.

So question, I am planning on the worst (and hoping for better), so for 1st two weeks I am telling myself it will be awful.  I'm seeing myself in recliner most of day, napping, being uncomfortable, trying to walk a little more each day... 

Will I be okay to write do you think?  With BMX?  I would like to address my christmas cards, there about 100 or so, I would do in small chunks.  This should be fine right? just sitting and writing?

NotAfraid - when did you have your DIEP at UCLA and who was your PS?

VickyAnn - if you want to connect with more people having surgery around the same time there are two groups for December - one is specifically for people having mastectomies and one is for any surgery, mastectomy or otherwise. Look for the threads and let me know if you can't find them and want to join. I'm active in both.

ReadingMama - I'm planning to grade exams after my surgery, probably won't start for a couple of weeks post surgery, but I have to try to get it all done, grades, narrative comments, etc... It sounds like it should be doable, we'll see.

Readingmama - Xmas cards shouldn't be a problem just work in small batches. Grading papers I think would be harder mentally but not physically. I found holding anything for long periods or trying to read a book or magazine difficult to hold and concentrate on. I found listening to books on my iPhone very enjoyable .

I had frozen shoulder 2 years after my lumpectomy and rads. Not fun. After DIEP I would warm up my shoulders in the shower and crawl them up the shower wall while standing in the spray. I avoided washing dishes and in particular putting them away for as long as possible. I have heavy dishes so I put my DH to work on the dishes. He never minds washing them but hates to put them away. I also would lay flat on the floor on my back and stretch my arms up and over my head as far as they could go comfortably. I would put a pillow on the floor behind my head(not under it) to help support the stretch until I could do it all the way without pillow support. I actually loved laying flat on the floor and quieting my mind for 10 minutes or so before I went to bed. Serimes I would fall asleep on the floor and my DH would have to wake me up to go to bed. Obviously don't try this technique too soon I think I stated it about 3 weeks out.

CookieMonst…

Dr. Festekjain was my PS and Dr. Prati was my breast surgeon.  I had 2mx/DIEP on March 29th. 

@VickiAnn - Beth Isreal hospital has a great movie online showing an actual MX and DIEP - and they explain what they are doing each step of the way... really helped me understand it much better.