Recently, our practice received questions from a breast cancer patient about a seemingly “new” type of living tissue breast reconstruction, coined the “APEX flap.” But is the procedure any different from the DIEP flap breast reconstruction Dr. Christine Fisher routinely performs? Below, she answers this question.
What is APEX Flap Breast Reconstruction and How Does it Differ from DIEP Flap?
The term “APEX flap,” being promoted by a group of microsurgeons in Louisiana, is an existing technique used by many experienced DIEP flap surgeons. This technique has been presented and published by the innovators of the DIEP flap procedure (such as Dr. Robert J. Allen, Sr., M.D.) for over 20 years. While the clever name may be a valuable marketing tool, and whether or not their term for it is service marked (SM–used to stake a business’s claim to a specific name or logo, a service mark is an unregistered mark), it is not actually a new technique.
The term “APEX flap” refers to a strategy of perforator (blood vessel) selection and rearrangement that minimizes the cutting of the muscle during the surgery. I have observed that some microsurgeons who are focused on short operative time as a metric of quality will take operative shortcuts, such as creating a longer opening in the abdominal fascia or cutting across the rectus muscle to quickly release vessels when the most important perforators span the width of the muscle along its course. These operative “shortcuts” can cause long term morbidities. A long fascial opening that extends to the pelvis can create long-term pain, a weaker abdominal muscle and even a low bulge. Cutting across the muscle to hurry the dissection weakens the muscle and may denervate it (cut the nerve supply).
Dr. Christine Fisher: Experienced DIEP Flap Microsurgeon
I am a board-certified plastic surgeon, a member of the American Society for Reconstructive Microsurgery, and a breast reconstruction specialist with a high-volume DIEP flap practice. I am proud of our very low return-to-operating-room rate (low rate of emergency operative take back and low revision rate) and provide compassionate care with a focus on a natural-looking result.
For my patients, I always plan the perforator (vessel) selection to prioritize the integrity of the muscle and nerves and to result in the shortest fascial opening possible. This includes strategically separating the small perforator vessels above the muscle and reconnecting them when necessary to protect the integrity of the muscle between widely spaced perforators. By reconnecting and rearranging the blood vessels, the surgeon can protect the integrity of the muscle when required due to the individual anatomy of a patient.
It is my belief that this is the normal standard of care for experienced and conscientious doctors who do a high volume of DIEP flap surgeries.