World-renowned surgeons at the Center for Restorative Breast Surgery in New Orleans have just published an article in this month’s edition of the Journal of Plastic and Reconstructive Surgery that unveils their newest pioneering advancement called the APEX FlapSM. In this landmark publication, entitled “Myth-busting the DIEP Flap and An Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review,” lead author, Dr. Frank J. DellaCroce, exposes little-known problems with popular reconstructive procedures for women facing mastectomy. They further describe how their group has innovated to fix the fundamental flaws of the widely known “DIEP” technique. “What we learned is that, despite popular perception, the DIEP procedure doesn’t always deliver on its promise of being a quality way to spare abdominal muscles and strength when performing natural tissue breast reconstruction. When forced, it can leave damage in the abdominal wall and produce a reconstructed breast with internal scarring and hard spots known as fat necrosis.” The surgeons spent over 8 years pioneering a way to reliably reduce the problems, improve cosmetic results, and add lasting softness to the newly reconstructed breast. Duly named the APEX Flap℠ to represent the quality improvements, this procedure has been performed routinely over the last decade at the Center for Restorative Breast Surgery (CRBS) with enhanced clinical outcomes compared to the DIEP alone.

As the paper states, the blood vessels can take unexpected paths as they pass through the abdominal structure and may not naturally fall in the right location for the older procedures. In these cases, doctors may cut through the “6-pack” muscles that are in the way, defeating the basic purpose of the DIEP technique. After seeing women referred in from around the country with problems, a pattern was noted in some women who had significant abdominal issues or rock-hard breasts after surgery. “They were surprised to learn that, before our publication, there was no framework to standardize how these procedures should be done or what they should be called,” states DellaCroce.

A total of 364 procedures were performed between 2011 and 2017 in the study with very low rates of abdominal problems or breast fat necrosis. Before the development of the APEX conversion, surgeons were left to choose between cutting the muscle and nerve bundles to bring more vessels together or sacrificing those vessels and reducing blood flow in the new breast fat. “We’re now able to produce consistently softer breasts compared to the DIEP alone and more reliably protect abdominal strength.” The surgeons at the CRBS use the APEX FlapSM as an alternative to TRAM Flap conversion when DIEP isn’t the best choice for maximization of blood flow and muscle preservation.

“The point is to deliver what patients think they are getting when they choose to have a procedure of this type.” Dr. DellaCroce and his colleagues also encourage practitioners to photographically document the quality of abdominal structure preservation in the patient’s medical record. “This encourages precision, I think. It lets us gather data about what we’re doing, and I believe it’s reassuring for the patients. If you can’t record the quality, you can’t make any assumptions about how your work was done,” states DellaCroce. “Documentation of this type is common in other fields like orthopedics and laparoscopic surgery, so adding it here is sensible and patients should ask about it.”

“The APEX FlapSM really brings this art into line with the premise of its concept. We have found that many women are not getting the results they expected from their DIEP Flap surgeries,” states Dr. DellaCroce. “We set out to open the dialogue on the little-discussed problems with existing procedures and create a solution for women who want the best in overall outcomes. We believe that open disclosure, technical progress, and objective documentation of work quality are how we best move forward with serving women who seek natural tissue breast reconstruction. The APEX FlapSM advancement is a big step in that direction.”

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.