Defining the “Gold Standard” in Breast Reconstruction with Abdominal Tissue

In an article published recently in the British Journal of Plastic Surgery, the first line of the abstract read, “The deep inferior epigastric perforator (DIEP) flap is the gold standard for breast reconstruction using abdominal tissue.” 1 Although I empirically agree with this statement, I wondered if this would be considered by the readership in a positive or a negative manner. I suspected that those who performed the operation would agree but those who did not would disagree. I then considered what the ratio was of plastic surgeons around the world who performed the DIEP flap compared with those who did not. This then led to the question, does this flap represent the “gold,” or accepted, standard for breast reconstruction using abdominal tissue or is this just the opinion of those few who perform it? The answer to this question is complicated but deserves discussion. It is not my intent in this discussion to criticize the authors who made the statement, because they have made significant contributions to our specialty and to the evolution of the DIEP flap. It is my intent to examine both sides of the issue in an attempt to come to a conclusion. A goal of our specialty has always been to advance the art and science of plastic surgery. Most plastic surgeons are curious, innovative, and always searching for novel techniques that will provide our patients with improved outcomes. When the transverse rectus abdominis musculocutaneous (TRAM) flap was introduced in 1982, it was considered a significant advancement for our specialty. 2 Surgeons from around the world began to perform this operation, and the women who had a TRAM flap were usually thrilled with the outcome. There was a general agreement and a group consensus among plastic surgeons that the TRAM flap represented the accepted standard for breast reconstruction using abdominal tissue. The DIEP flap was introduced in 1989 and then later popularized as a means of minimizing the complications related to the abdominal wall that were associated with the pedicle TRAM flap. 3–5 There were increasing concerns about the abdominal donor site, and a substantial number of women began to voice their dissatisfaction regarding the appearance and function of the abdomen. The DIEP flap was able to overcome the limitations of the conventional TRAM because the anterior rectus sheath and rectus abdominis muscle were only incised and not excised, thus preserving the elements responsible for the support and strength of the abdominal wall. 6–8 So why has the statement arguing that the DIEP flap represents the new “gold standard” in breast reconstruction with abdominal tissue generated such controversy? In order to state that a procedure represents an accepted standard, a general consensus is usually required. In addition, the implications of a procedure touted as the accepted standard are subject to varying interpretations. Some may interpret that the accepted standard represents the method that all should perform, whereas others may interpret that the accepted standard represents a level that we must all strive to achieve. They are both correct. Women interested in breast reconstruction would argue that if the DIEP flap is the accepted standard then it should be offered to or at least discussed with everyone. Many surgeons would argue that the DIEP flap is not the accepted standard because it is performed by so few and does not represent the “standard of care.” They are both correct. These differences in the interpretation can be a potential point of conflict that has historically resulted in medical legal activity. For a surgical procedure to be considered an accepted standard, there should be a general consensus by the majority of plastic surgeons who perform breast reconstruction. At this point in time, it is premature for one individual or a small group of individuals to publish such a statement because the general consensus would argue that the DIEP flap is not the new accepted standard (at least in the United States). One can make the assumption that over time the DIEP flap will gain in popularity and be performed by many plastic surgeons. I am confident that in the next 10 years, as plastic surgery residents in training learn this operation, there will be more DIEP flaps performed compared with TRAM flaps. However, at this point in time there are far more TRAM flaps performed compared with DIEP flaps. The principal reason for this is that performance of the DIEP flap is very complex and requires expertise in microvascular surgery; the conventional TRAM does not. Most surgeons today prefer and continue to perform the pedicle TRAM flap because it has an acceptable complication rate, they choose not to engage with microvascular surgery, and women are generally pleased with the outcome. During a consultation with a plastic surgeon who does not perform the DIEP flap, the surgeon is not likely to mention this option. In order for a woman to learn of the DIEP flap, independent investigation is usually required. This then leads to another important question. Should plastic surgeons provide options for breast reconstruction that they personally do not perform? When women are considering breast reconstruction, most are usually referred to the Web site of the American Society of Plastic Surgeons and/or given a brochure that is published by the society. When women read this material, the only abdominal option discussed is the pedicle TRAM flap. The DIEP flap is not mentioned. Reconstructive surgeons who do not perform the DIEP flap usually do not discuss it, and if they do, they do so in a negative manner, commenting on its complexity and risk of total failure. All plastic surgeons prefer an operation that is reliable and predictable, and to the reconstructive breast surgeon who does not perform microsurgery, the pedicle TRAM flap is both and the DIEP flap is neither. This said, should all options, including the DIEP flap, be discussed? The unfortunate reality is that we practice in a highly litigious environment and the medical-legal ramifications of omitting the DIEP flap option may one day become an issue. This will certainly not fall favorably in the minds of those surgeons who do not perform the DIEP flap; however, it would be an underestimation to think that it could not occur. In summary, I believe that it is premature to state that the DIEP flap is the new “gold” or accepted standard for breast reconstruction using abdominal tissue, despite its benefits and advantages. The accepted standard should reflect the standard of care that is provided within a given community and should be defined accordingly. For a given procedure to be referred to as the accepted standard, it should be based on the collective opinions of the majority of plastic surgeons, not the minority. It is unfair to say to plastic surgeons who have been performing the TRAM flap for years and who have been providing their patients with excellent care that they no longer meet the current standards because they do not perform these complex reconstructions. It is unfair to say that a given procedure represents the accepted standard when it is performed by less than 5 percent of plastic surgeons, especially when its counterpart, the pedicle TRAM flap, is performed by more than 90 percent of reconstructive surgeons. The standard of care requires that surgeons meet the standards within their community of practicing physicians. It does not require that surgeons provide an option that is above the standard of care. Market forces and consumer demand may eventually swing the pendulum toward the DIEP flap. However, for the time being, it would behoove the plastic surgeon to at least mention the DIEP flap as an option.