DIEP Flap Breast Reconstruction
Patient phenotype
Post-mastectomy reconstruction (immediate or delayed). 40s-60s. Often post-radiation. Comorbidities: smoking history, DM, prior abdominal surgery (relative contraindication).
Procedure
Long microsurgical case (4-8+ hours). Lower abdominal flap (perforator-based, sparing rectus muscle) tunneled or transplanted with microvascular anastomosis to internal mammary or thoracodorsal vessels.
Anesthetic plan
GETA + TAP block (postop abdominal pain) + Pec block (chest). Same free flap principles: warm, well-perfused, hemoglobin 25-30%, avoid alpha-agonists (controversial).
Setup
- ·A-line
- ·2 PIVs
- ·Foley
- ·Forced air warmer + fluid warmer
- ·Type & screen
- ·TAP + Pec blocks
- ·Sequential compression devices on lower extremities
Biggest concerns by phase
Smoker + flap viability
Smoking 4× failure rate. Cessation 4-6 wks pre-op required. Nicotine vasoconstricts → flap loss.
Same as free flap — perfusion priorities
MAP > 80, HR < 100, Hgb 25-30%, normothermia, normocarbia, normal pH. Vasodilators preferred over fluid for hypotension. NE controversial (use only if true vasodilation, not hypovolemia).
Long case management
Position checks q2h, pad pressure points, warm everything, antibiotic redosing, glucose control, fluid balance.
Anastomosis time + observation
Do not disturb at anastomosis. Quiet field. Surgeon may use Doppler to confirm flow at end.
Smooth + ICU/floor with frequent checks
Smooth emergence (no shivering, no bucking — pulls on anastomosis). Postop flap checks q1h × 24h: color, temp, capillary refill, Doppler signal. Anesthesia handoff explicit.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
55-yo F post mastectomy + radiation 6 mo ago, DM (HbA1c 7.2), former smoker (quit 8 mo), DIEP flap reconstruction. Plan?
What an examiner probes for
- ▹Same free flap principles (warm, perfused, normovolemic)
- ▹DM glucose control
- ▹TAP + Pec blocks for analgesia
- ▹Position changes, pressure point care
- ▹Postop flap monitoring
Sources
- Miller's Ch 64
- Plastic Surgery Anesthesia Review
Anatomy reference
Sourced reference images. 4 matches for "breast abdomen vessels".
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