Response from a PS regarding plication:

Full "tummy tuck" closure with DIEP flap breast reconstruction... A good idea?

"It is possible to do rectus plication with DIEP flap donor site closure for a full abdominoplasty result"

Karen M. Horton, MD answers: Possible to do full tummy tuck while doing diep flap procedure?

When the DIEP flap (deep inferior epigastric artery perforator flap) is used for microsurgical breast reconstruction, usually a small split is made in the muscle fascia (thick layer of collagen over top of the rectus abdominis muscles) to dissect out the blood vessels used for transplantation of skin and fat from the tummy to the breast.

Usually, the fascial split is simply closed, and the overlying anterior abdominal wall (sheet of skin and fat over the muscles of the trunk) is pulled tighter and closed, resulting in a tummy tuck scar.

It IS possible to perform rectus fascial plication (corsetting of the rectus abdominis muscles of the abdominal wall towards each other in the midline AT THE TIME of DIEP flap donor site closure.
However, doing so may change the pressures inside the abdominal cavity (i.e. on the stomach, intestines, diaphragm, etc) and may increase the risk of complications to the flap circulation in the short term. The worst case scenario would be to perform cosmetic steps during surgery and to lose the flap altogether!

Performing a full tummy tuck closure with the DIEP flap is something I HAVE performed successfully on a number of occasions, but patients must be very carefully selected and we would all have to be willing to accept an increased risk for complications.

I am currently reviewing my results on this combined procedure and will be presenting my work at upcoming meetings and in the form of a scientific paper, to be published on my website.

Often, the best solution is the simplest. On the day of your DIEP flap, it is usually best to focus only on microsurgical success. "Touch-ups" can be done any time in the future, including liposuction contouring of the abdomen (done in most of my patients) together with their nipple and areolar reconstruction, and/or rectus fascial plication, if needed.

See the photographs below of an example of rectus fascial plication done either at the time of DIEP flap donor site closure.  Trust your Microsurgeon to make the best decision for you, and to ensure a SAFE and SUCCESSFUL breast reconstruction as the #1 goal!

I am three months out with my stage one DIEP I still have muscle weakness, and can't sit up in bed without pain. I am confused because the one of the reasons I went with the DIEP so I wouldn't have this problem. Asked my PS about it he said do half sit-ups which has helped some. I just had my stage two Monday and told my DD that it didn't hurt any more, she reminded me that I am still on drugs (duh). I want to know what other people have done about this problem, when I go back next week for my post-op I can ask him again.

CookieMonster: Did you have to ask Dr. F. to fix the muscle or he just did it?

DIEP +6-Thursday



Great morning lots of walking and moving. She had a great night sleep. After a while pain started creeping back so we went to happy pills. She went to sleep in the morning and woke up feeling great. She wanted me to go and get her spanks in case the PS took the two remaining drains out. I went to Kohls and waked all around the lingere department and could not find them. I'm glad I had my 16 year old daughter with me so didn't look like a total creep. Got another brand. Not sure they're going to work.



We went to the PS at 3:30. The walking went well but when we went in, the first thing he did was pull one of the remaining drains. That mixed with the Oxy made her very nauseous. The doctor had to stop talking for a bit and get her water. He is very pleased with the results so far and wanted to show her. She is not ready for the mirror so he explained it to me.



We received about five new flower arrangements and our second meal delivered by friends. Very helpful.



All in all a good day. It was great to get out. On the way back from the doctor's, we sat in the car watching people walk by while we ate soft serve cones. Lesson: don't wait for the pain to get bad. Take the pills as prescribed. She had a much better day today. Listen to your body and don't expect the next day to be better. You'll have ups and downs.

Hi,

Schedule for bi lateral diep on the 26th at us in Seattle. Scared stiff! 2 years out from bi lateral mast,

6 rounds of chemotherapy and 33 radiations. Dread the whole hospital mess. How tough is this going to be? Thanks, pigal

Hi pigal60. Welcome, and you'll read a lot here that should help you. The #1 thing is that it's worse in the anticipation. Just comfort yourself with this (and DIEP 2011 thread) to make yourself feel more like you know what it can be like, the highs and occasional lows. Your job is easy: once you pick a surgeon that knows what he or she is doing and has enough DIEP experience, you just have to wake up (probably pretty early) and show up on time and go back to sleep. It's slow getting around at first but every day is a little better, and soon, you will be wondering why you were so anxious.

I agree with goldlining.  Athough I wasn't that anxious, I was so ready to get it over with and start with recovery.

After, you will have some days when you're really tired but other days where you can go all day.

For me, the whole thing is still pretty surreal--I had BMX with immediate DIEP.  It's been almost 3 weeks since my surgery and the boobies look just more swollen than before (with some stictches) . . . my abs are not sore, just too tight to stan up straight. Everyone who has seen me does not believe that I had major surgery only 3 weeks ago (and this was at 2 weeks out too) . . . until they see me walk.  It's not that I can't get around, but I'm a little slower and kinda hunched over from the ab tightness (I look like a little old lady with osteoperosis)!

Janet, The only really bad part for me was that I wasn't allowed out of bed or to use my arms while I was in the hosptial.  In some ways, though, that wasn't bad b/c I wasn't using any of the potentially sore muscles.  I felt a bit trapped, but slept through most of it.

Lala63 -- I really appreciate your reports and am following your wife's progress with interest. You are an awesome husband!

pigal60 -- Welcome! I am in Seattle and scheduled for DIEP on May 24th. This board is a great source of information and comfort.

Dressager.. I used my arms in the hospital, used them to get in and out of bed, used them to shower, get dressed, do my dressings.. I just didn't lift anything heavy.

Dressager- I used my arms too. The Foley was taken out on day 2 and I was encouraged to move around after that. I used my arms to get in and out of bed and for anything I would normally use them for except any lifting. And by day 2, I mean the next day after surgery.



Janet- got your PM. I'm out of town and on my iPad. I'll answer when I get home. I'm too wordy for this little keypad. Lol

DIEP + 7-Friday

 One week!  She had a good day.  Drove around a bit and parked to watch people walk by.   She kept up her Oxy which made her constipated.  Lot of visitors in the evening which made her very happy and tired at the same time.  At night all the kids were gone so I got Vietnamese food.  The chicken had cabbage which gave her gas and with the constipation it was very painful.  Popped another magic pill and went to sleep.Didn't move around much.

 The PS texted to say he coundn't meet us at night to remove the final drain so we shcedulued for Saturday in the morning.  She really hasn't been very bothered by the drains so it wasn't a big deal.  

DB53: thanks so much good to know someone else was thinking the same thing. I do agree with you we are more than a a pair of breast I guess some days I just feel she there are not good choices here, so as someone esle said no breast = no cancer; April 23rd here I come...

DIEP+8 & 9 Saturday and Sunday



Saturday was a great day. At 10:00AM we met the PS and he removed the final drain. We drove around all over and she did great in the car. Oxy every six hours. Later she drove around with her sister while I went to a soccer game. BM in the morning.



Easter Sunday she guilted us into going to church to pray for her. Later,she decided not to go to her brother's. No pain but she wanted to make sure she was ok. First oxy at 5:00PM. Long shower and first time she looked at the new chest. It went OK.



So after one week, she is still in pain but she is getting around just fine. She has no drains and her spirits get better every day. I already see her getting bored and my guess is she'll be back to work in a couple of weeks. I may have to lock up her lap top in the next few days. In some ways her recovery is faster than we expected but the pain is lasting longer than I would've guessed based on her tolerance to pain.



Her way of coping has been to avoid everything. That is how I ended up on this blog looking for information. Some want to know more some don't. We all handle things in our way and my posts help me.



This is tough even when everything goes well. I can't imagine what some of you brave women and your families have been through and I hope my wife's story helps. My thoughts and prayers are with you all.

So good to hear from you, Elisabeth! It sounds like you've been through the wringer but made it through to the other side. I look forward to more updates as you can.

Hi all I am scheduled for my first phase of the DIEP this Friday April 13th.  Yes I know that date isnt the greatest but for me it is my lucky day!  I think I got all of my questions answered by PS but forgot to ask about recovery time.  I"m assuming I will be out of work for about 6 weeks but wanst even sure.  How long did it take for you all to start feeling good enough to go to work.  I am just dreading the drains as that was the worst for me when i had my bmx in November.  Finished chemo in Feb and have waited 9 weeks for this day to come.  I cant wait and am actually excited.  Hoping to get the right size this time or else I may have to get small implants in phase 2 but hoping to avoid that.  I'm not a small person so B cups just dont look quite big enough for my taste.  Hoping for a C cup but not sure we can get there.  Wish me luck!  Looking foward to hearing more about everyone's experience.