Patients who will undergo mastectomies as part of breast cancer treatment now have a new option for natural breast reconstruction in Rhode Island.
Care New England Health System has begun offering a procedure known as the “DIEP” flap technique at Kent County Memorial Hospital in Warwick. DIEP – deep inferior epigastric perforator – is the name of the blood vessels used in the procedure during which surgeons take skin, fat and those blood vessels from the lower abdomen of the patient to create a new breast with natural-looking contours.
The reconstruction is complex, however, because it involves connecting tiny blood vessels and nerves in the abdominal tissue to the chest wall.
“This is on the extreme end of the delicacy in terms of surgeries that we do in plastic surgery,” said Dr. Erik Hoy, chief of Kent Hospital’s Division of Plastic and Reconstructive Surgery.
Indeed, Hoy says the hospital has been working for several years to recruit a microsurgeon capable of performing DIEP flap operations.
“Any plastic surgeon can do these procedures, but most of them wouldn’t be successful,” Hoy said. “You really need to have a very specialized and very talented microsurgeon to do that.”
Hoy says the health system found the skills needed for the procedure in Dr. Brian Temple, who was hired in February 2024.
Temple started at Kent in September 2024 after completing a yearlong fellowship in reconstructive microsurgery – where he focused on the DIEP flap procedure – at the Yale School of Medicine.
But getting the hospital prepared for such an intricate procedure took months.
Temple says he gave presentations to the staff in the intensive care unit on how to monitor the incision sites and how to use a special device needed after the procedure to ensure success. Because Care New England had never performed a procedure that requires relocating tissue from one part of the body to another to repair or reconstruct damaged tissue, Temple also provided guidance to operating room nurses and anesthesiologists.
“It takes an army,” Temple said.
Hoy says the hospital began preparing for the procedure even before Temple was hired, acquiring specialized equipment such as the microscope surgeons would need to view minuscule vessels and nerves and the device that monitors the flap’s circulation after the procedure.
“I’ve never had to go through that before for a procedure,” Hoy said, adding that hospital executives and staff discussed the procedure and its protocols for months.
Now two DIEP flap operations have been completed successfully at Kent and there’s a list of 30 more patients awaiting the surgery, Temple says.
Before this, breast cancer patients were typically referred to hospitals in Boston or New York if they opted for DIEP flap reconstruction after a mastectomy, but Hoy says he was motivated to offer it in Rhode Island, in part because Care New England is home to some of the state’s busiest breast cancer centers.
Part of the advantage of this surgery is that no muscle is removed from the abdomen, as it is in other procedures. That reduces the risk of hernia and muscle damage. The surgery leaves a scar that runs horizontally across the lower abdomen, but doctors say it usually heals well and can be concealed.
The procedure can take up to eight hours to complete if one breast is reconstructed, and up to 12 hours for both, Temple says.
He doesn’t do it alone. He works with two microsurgeons from The DIEP Group, which is a group of five microsurgeons who travel to smaller hospitals throughout New England to assist with breast reconstruction.
Temple says every patient is screened before the procedure to ensure they have enough tissue, which is one of the most common limitations. Also, he checks if a patient had an abdominoplasty before or any other surgery that might change their anatomy in a way surgeons can’t use the arteries or veins they need. Because the procedure involves tiny blood vessels, patients are also assessed for hypercoagulability, a condition that causes someone to get blood clots.
During the procedure the surgeons remove skin that is normally taken as part of an abdominoplasty, or a tummy tuck, and dissect the artery and vein attached to that skin flap and then connect the flap to a vessel in the chest to reconstruct the breast, Temple says.
After the procedure, patients stay in the hospital for about three days and are out of work for two weeks, with a full recovery expected within four to six weeks, Temple says. Even though they’re not necessarily ICU patients, partly because there’s not much blood loss, they stay in the intensive care unit because the flap needs to be monitored several times a day.
One of the procedure’s biggest risks is that the flap doesn’t work, meaning it doesn’t have blood circulation and the tissue dies.
“You have very intricate surgery that takes a very long time. But it’s really not a big risk to the patient,” Temple said.