Just as there have been advancements in breast cancer screening and therapy, there have also been advancements in breast reconstruction procedures following mastectomy. There are several reconstructive techniques available, each with its own set of indications, contraindications, benefits, drawbacks, and consequences. Breast reconstruction following mastectomy is oncologically safe and linked to high satisfaction and better psychosocial results.
Breast reconstruction is now an option for the majority of women who need to have a mastectomy. Reconstruction may take place immediately after the removal of the breast or a portion of the breast, or it may take many months after the conclusion of adjuvant therapy, if necessary. Some women may want to wait a few years before contemplating delayed breast reconstruction, if at all. When confronted with the necessity for a mastectomy, every woman should be able to make an informed choice about whether or not to have breast reconstruction.
Dr. Dmitry Melnikov is the National Vice Secretary for the International Society of Aesthetic Plastic Surgeons (ISAPS) and an active member of the World Society of Reconstructive Microsurgery. In this discussion, he details the differences between SIEA and DIEP, and shares patient outcomes.
Dr Dmitry Melnikov, National Vice Secretary for the International Society of Aesthetic Plastic Surgeons (ISAPS)
Tell as about the SIEA and DIEP flap procedures. How do they differ from one another?
Superficial Inferior Epigastric Artery (SIEA) and Deep Inferior Epigastric Perforator (DIEP) flaps are cutting-edge breast reconstruction procedures that use a woman's own tissue to create new breasts after a mastectomy due to breast cancer.
Similar to a DIEP flap, a SIEA flap involves moving a different section of blood vessels with fat and skin from the belly. While a DIEP flap requires a minor incision in the abdominal fascia—the casing of organs, a SIEA flap is a less intrusive form of surgery that doesn’t require an incision.
The DIEP flap procedure is likened to organ transplantation. However, DIEP is autologous—which means the donor tissue is taken from a different body part of the same patient and shaped into whatever the surgeon needs it to become. For instance, tissue taken from a patient’s stomach can be shaped into a new breast or used to cover any major traumatic defect.
To perform the procedure and reconstruct a breast, surgeons use a flap of complete tissue comprising skin, fat and blood vessels from the lower abdomen, leaving the abdominal muscle intact. The DIEP flap is the most advanced form of breast reconstruction, offering patients a natural looking and feeling breasts. It is a major surgery that requires general anesthesia.
How does this procedure differ from cosmetic surgery and silicone? What are the benefits vis a vis typical plastic surgery?
Plastic surgery per se involves foreign substances injected into the body, such as silicone or other foreign objects that many women prefer not to live with. The recovery time from a DIEP flap is shorter as the patient wouldn’t need to wear a tissue expander for months as required in the case of silicone. A DIEP flap combines both aesthetic and reconstructive surgery. It is wrong to say that plastic surgeons are simply beauticians. All the face transplants in the world are done by plastic surgeons.
When it comes to breast reconstruction, autologous tissue is a natural extension of the body and once transplanted and alive, it will stay for life. The risk of failure is almost nonexistent. A DIEP flap doesn’t require maintenance or replacement like silicone implants. It’s soft, natural and most importantly, it’s alive. Silicone implants have been reported to cause complications including implant deflation, rupture, extrusion, or seromas due to improper healing of the surgical wound.
Besides the medical and aesthetic benefits, what is one of the major advantages of DIEP for women?
DIEP flap is known to give female cancer patients a moral boost since they view their breasts as a vital aspect of their femininity. DIEP gives women back what cancer had taken away from them. Breast cancer patients often have adequate skin and fat in the lower abdomen that can be used to reconstruct one or two breasts. Women with previous medical conditions and prior abdominal surgery may also undergo this operation, making almost all women candidates for this surgery.
How was the feedback from patients in previous surgeries?
Some patients have reported higher levels of confidence and comfort with their bodies following DIEP flap than they had prior to their diagnosis. Six years ago, I performed a DIEP flap on patient Olga Ushakova. With no muscle trauma during her surgery, Olga perused a career in sports and she is currently a champion in the European powerlifting competition.
Another patient of mine, Elena Maltseva has undergone the reconstructive surgery with an implant and latissimus dorsi (flap from the back). Today, she perceives her personal image more positively compared to the time of her diagnosis with cancer.
What is the role of AI and big data in this procedure?
AI and technology serve as a great enabler of this modern-day surgery. Technology mostly helps in the planning and preparation phase of the surgery.
While nobody used MRI technology for DIEP planning before, I use a custom protocol of abdominal wall 3-D modelling before the surgery to visualise and locate the right perforator vessel that will be used when harvesting the flap. Technology allows me to analyse the patient anatomy, providing me with a detailed 3D model of the patient vessels. All this contributes to the speed and quality of the surgery, helping me navigate to the intended areas with ease, perform the surgery with high precision, minimal incision, barely touching the muscle.
I also use big data from computer tomography to study patient anatomy before the surgery.