1. Microvascular abdominal flap reconstruction Stephen McCulley Consultant Plastic and Oncoplastic Breast Surgeon Nottingham

3. Bilateral DIEP Surgery ‘Optimal breast’ ‘Optimal abdomen’

6. Superior Epigastric Artery Pedicled TRAM Deep Inferior Epigastric Artery Free TRAM DIEA – DIEP flap Superficial Inferior Epigastric artery – SIEA flap

7. DIEP flap

8. Free TRAM or MS-TRAM

10. SIEA flap pedicle

14. Pedicled TRAM vs DIEP/Free TRAM “Both are good operations”

19. Vascularity I II III IV Zones I always (and zone III usually) safe in pedicled TRAM Zones I and III always (and zone II usually) safe in free TRAM/DIEP M ain cause flap loss/partial loss is VENOUS problems

20. Complications in Pedicled TRAM Breast Reconstruction Spear, Scott L. M.D.et al PRS 2005.

22. Freedom of size of flap and/or need C/L reduction

24. Performing a DIEP flap

33. Single muscle split for most If very medial then dual incision Preserve Intra-mural nerves Lignocaine for muscle

36. Position flap properly - Set up for success De-epithelialise superior edge

37. Usually do microsurgery standing

48. Abdomen closed with patient bent

49. Insert flap from mastectomy scar to crease Excise or de-epitheliailise depending on skin needs

52. Primary reconstruction

53. Good SSM essential to a good primary reconstruction

55. Lateral Lolli-pop incision

56. Vertical

57. Peri-aereolar mastectomy

58. Transverse

59. Skin paddle when needed for scars, tumour, previous radiotherapy or vascularity

60. Recurrent Invasive tumour Left breast – 70 years age

61. Large skin paddles

62. Wise pattern

64. DIEP and radiotherapy Debate about impact over time. MD Anderson , PRS study findings of significant impact being challenged

66. Bilateral DIEP Surgery

71. Secondary reconstruction

72. Delayed left reconstruction using DIEP flap. Patient in her 60 ’s

73. Pre-op Delayed DIEP flap Minor liposuction & Nipple reconstruction Stages of Secondary DIEP flap reconstruction

76. Implant salvage