 "The sacrifice of the rectus abdominus muscle is a less desirable option when there are techniques that allow for use of the same fatty tissue with preservation of the ventral abdominal muscle wall. The recovery is less arduous with less pain and narcotic requirement (as documented by Kroll et. al; see attached). Long term problems with abdominal bulge/hernia and weakness are also lessened if not eliminated (as documented DellaCroce et. al, Blondeel et. al, Keller, and Kassman et. al; see attached). The DIEP flap technique is more complex and technically more difficult to perform successfully than the free TRAM flap without formal training and significant experience in perforator flap surgery. It is generally accepted that the DIEP is therefore not best undertaken by the occasional microsurgeon. Arguments that patients may be a candidate for the free TRAM but not the DIEP based on perforator “appearance” or “size” have not been validated in our experience with over 700 cases. We have never found a situation that required conversion of a planned DIEP to a TRAM. The same blood vessels are employed for both operations and multiple perforators may be included with the DIEP flap. The likely basis for arguments along these lines is a lack of comfort dissecting around very small perforators and concern for injuring them which is buffered by taking the surrounding muscle. We have not found that the sacrifice of the rectus musculature facilitates these technical matters. Operative times for our group, performing between 4 and 9 of these procedures per week, averages 3½ hours for a unilateral reconstruction and 5-6 hours for bilateral reconstruction. Limited operative times, as you well know, improve the safety profile of procedures in general. The national average for successful free tissue transfer of all types is reported in the 93-94% range. Success rates less than this may require some reexamination of techniques employed. Our case volume has allowed for continued increases in efficiency and as a result keeps our success rate with these free tissue transfers in the 99% range. It is our belief that procedures that subject patients to less pain, shorter recovery, and less long term mobidity are in keeping with nationally recognized professional standards and provide clear benefit to women seeking breast reconstruction. Ms. _____'s surgery will require the assistance of a second microsurgeon and her anticipated hospitalization would be for 4 days. Second stage reconstruction, to include nipple reconstruction and flap/donor site contouring (if required), would follow a minimum of 8 weeks later and would be performed on a outpatient basis. Nipple-areolar tattooing is the final stage and is completed as a minor office procedure. Thank you in advance for your attention Ms. _____'s care needs and your interest in the well being of your network members." |
