DIEP Flap Breast Reconstruction
Breast defect following mastectomy for [breast cancer / prophylactic mastectomy]
Same
Deep inferior epigastric perforator (DIEP) flap breast reconstruction, [right / left / bilateral]
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
Patient with history of [breast cancer / BRCA mutation] status post mastectomy desiring autologous breast reconstruction. Adequate abdominal donor tissue available. [Prior radiation to chest wall.] CTA perforator mapping performed preoperatively. Dominant perforators identified at [zone / location]. Risks including flap loss, fat necrosis, abdominal hernia, asymmetry, and prolonged operative time discussed. Consent obtained.
Perforator vessels identified as planned on preoperative CTA. Dominant perforators: [right / bilateral] periumbilical. Pedicle length [X] cm. Venous drainage via [single / double] accompanying veins. Recipient vessels: internal mammary artery and vein at [second / third] intercostal space.
The patient was positioned supine and prepped from chest to mid-thighs. Two surgical teams proceeded simultaneously.
FLAP HARVEST: An elliptical abdominal skin island was marked centrally including the umbilicus. The skin island was incised and the flap raised by dissecting through the abdominal fat to the anterior rectus fascia. The dominant perforator(s) were identified entering the fat and dissected retrograde through the rectus muscle, carefully separating muscle fibers without dividing them (intramuscular dissection). The pedicle was traced to its origin from the deep inferior epigastric artery and vein. Pedicle length [X] cm achieved. The flap was divided and passed off the table. Anterior rectus fascia closed with [running 0 PDS / mesh]. Drain placed. Abdomen closed in layers. Umbilicoplasty performed.
RECIPIENT SITE PREPARATION: The [second / third] intercostal space was accessed [by excision of the intercostal cartilage / using a rib-sparing technique dissecting through the intercostal space]. The internal mammary artery and vein were exposed and isolated under loupe magnification.
MICROVASCULAR ANASTOMOSIS: Under the operating microscope, end-to-end anastomosis was performed between the DIEP pedicle artery and internal mammary artery with [9-0 / 8-0] nylon interrupted sutures. End-to-end venous anastomosis was performed [with a [3-mm] microvascular coupler device / with [9-0] nylon interrupted sutures]. [A second venous anastomosis was performed between the [deep inferior epigastric vein / superficial inferior epigastric vein] and the [second internal mammary vein / thoracodorsal vein] to optimize venous outflow.] Clamps released with brisk flap perfusion and venous outflow confirmed. Handheld Doppler signal [audible].
The flap was inset and contoured to recreate the breast mound. Excess skin de-epithelialized. Flap dermis inset with 3-0 Vicryl. Skin closed with 3-0 Monocryl. Patient tolerated the procedure well.
None
None
[200-400] mL
[Two] JP drains: [one] at flap, [one] at abdominal donor site
Patient taken to PACU/ICU in stable condition. Hourly flap checks initiated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Breast defect following mastectomy for [breast cancer / prophylactic mastectomy]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Deep inferior epigastric perforator (DIEP) flap breast reconstruction, [right / left / bilateral]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with history of [breast cancer / BRCA mutation], status post mastectomy desiring autologous breast reconstruction. Adequate abdominal donor tissue available. [Prior chest wall radiation.] Preoperative CTA perforator mapping identified dominant perforators at [zone / location]. Risks including flap loss, fat necrosis, abdominal hernia, and prolonged operative time were discussed. Informed consent obtained.
FINDINGS: Perforators identified as planned on preoperative CTA. Pedicle length *** cm. Venous drainage via [single / double] accompanying veins. Recipient vessels: internal mammary artery and vein at [second / third] intercostal space.
DESCRIPTION OF PROCEDURE:
Patient positioned supine. Prepped chest to mid-thighs. Two teams proceeded simultaneously. FLAP HARVEST: Elliptical abdominal skin island marked centrally including umbilicus. Flap raised through abdominal fat to anterior rectus fascia. Dominant perforator(s) dissected retrograde through rectus muscle without dividing muscle fibers. Pedicle traced to origin from deep inferior epigastric artery and vein. Pedicle length *** cm achieved. Flap divided. Anterior rectus fascia closed with running 0 PDS. Abdomen closed in layers. Umbilicoplasty performed. RECIPIENT SITE: Second/third intercostal cartilage excised [rib-sparing technique used]. Internal mammary artery and vein isolated under loupe magnification. MICROVASCULAR ANASTOMOSIS: Under operating microscope, end-to-end arterial anastomosis with 9-0 nylon interrupted sutures. End-to-end venous anastomosis with 3-mm coupler device [second venous anastomosis performed]. Clamps released. Brisk perfusion and venous outflow confirmed. Doppler signal audible. Flap inset and contoured to recreate breast mound. Excess skin de-epithelialized. Dermis inset with 3-0 Vicryl. Skin closed with 3-0 Monocryl. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: Two JP drains (one at flap, one at abdominal donor site)
DISPOSITION: Patient taken to PACU in stable condition. Hourly flap checks initiated.
Signed: .ME, .MYDEGREE
.TODAYVariants
TRAM flap (pedicled)
Pedicled on the superior epigastric artery (continuation of internal mammary). The entire ipsilateral rectus abdominis muscle is mobilized and tunneled subcutaneously to the chest — not a muscle segment. Document muscle preservation attempts, degree of muscle sacrifice, and fascial closure technique. Higher hernia/bulge risk than DIEP due to full muscle harvest.
Bilateral DIEP
Two separate flaps for bilateral reconstruction. Document bilateral pedicle harvest, recipient vessel preparation, and anastomosis for each side. Billing: Medicare bilateral-procedure reporting on a single line (1 unit); some commercial payers require right- or left-side reporting on separate lines. Document bilateral operative planning in the note.
Delayed reconstruction
Secondary procedure after prior mastectomy and radiation. Document scar tissue management at recipient site and vessel quality.
Charting Tips
- Document preoperative CTA perforator mapping findings including perforator location (zone), number, and caliber
- State pedicle artery and vein size at takedown
- Flap perfusion assessment: Doppler signal, color, capillary refill at completion
- Abdominal fascial closure technique (primary suture vs. mesh reinforcement) — document explicitly given hernia/bulge risk
- Postoperative flap monitoring protocol must be established (frequency, clinical parameters, rescue plan)
Documentation & Reimbursement Considerations
- Report DIEP Flap Breast Reconstruction as the primary service when it is the definitive operation performed.
- Verify payer-specific preference before submitting.
- Global period is 90 days. All routine post-op care is bundled. Flap monitoring visits and standard wound care are not separately billable.
- Document distinct roles in the operative note.
- Bilateral reconstruction: for Medicare, append bilateral-procedure reporting to a single line item (1 unit); reimbursement is 150% of the unilateral fee schedule amount. Some commercial payers accept right- or left-side reporting on two separate lines — verify payer policy.
- Recipient site vessel preparation (internal mammary artery and vein dissection) is bundled into the primary service. Document the rib excision as a distinct step if performed.
- Document flap harvest dimensions, recipient vessels used, ischemia time, number of arterial and venous anastomoses, and method of anastomosis (end-to-end vs end-to-side) for both clinical accuracy and coding defensibility.