Anatomy Overview:

• While only been around since the late 1980s, it has become extremely popular and is now considered the “Gold Standard” in autologous breast reconstruction
• Offers abundant, well vascularized tissue with a reliable, long pedicle that can be used not only for breast reconstruction but for any large defect requiring bulky reconstruction 
• Compared to it’s predecessor the TRAM flap, there is little to no functional donor site morbidity 
• The pedicle to our flap is DIEA
• Originates from the external iliac artery just proximal to the inguinal ligament
• Runs superomedially between peritoneum and transversalis fascia
• Most commonly divides into a medial and lateral branch which give off our medial and lateral “row” perforators
• 90% of these DIEA perforators are located within a 6cm radius, inferior and lateral to the umbilicus 
• Our venous drainage is typically via 1-2 vena comitans that run with the artery
• Can also have accessory venous drainage from SIEV system which I am sure we will get in to during our discussion 

Topics Covered:

• As we all know – you use the DIEP flap commonly for breast reconstruction. In your opinion what are the major advantages of this flap specially for breast reconstruction. 
• Do you have any hard or relative contraindications for use of the DIEP flap? BMI cutoff? Prior abdominal surgeries?
• As Duke residents we know that you get preoperative CT scans on all of your patients. How do you use these images to make preoperative decisions? 
• Technical Dissection Steps: 
• In terms of the abdominal donor site – how do you make the decision about where to place your markings? 
• Perforator selection – I have noticed that you often commit to 1 or 2 perforators to base your flap on which decreases operative time. How do you make these decisions intraoperatively? 
• Overall how do you maximize efficiency in the operating room?
• For unilateral breast reconstruction you often use a stacked DIEP flap. Can you talk a little bit about the “stacked” DIEP flap and what you think are the advantages of this DIEP variation?
• What do you think is the next step in the evolution of the DIEP flap and breast reconstruction in general?
• Have you used a DIEP flap for a defect outside of breast reconstruction? What other kind of defects do you think this flap is suitable for?

Any final important thoughts on breast reconstruction using the DIEP flap? 

Bonus – What is one of the most influential or most memorable pieces of advice you received as a plastic surgery trainee and how that has influenced your practice?