/Descent -213 The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. /Resources 48 0 R We offer surgical and non-surgical options, like 3-D tattoo, that allow our surgeons to create a natural appearing nipple as the final touch for your breast reconstruction. -, Mathes S.J., Nahai F. Classification of the vascular anatomy of muscles: Experimental and clinical correlation. Before /Encoding /MacRomanEncoding Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations. I do hope that as time goes on your symptoms will improve. The authors declare no conflict of interest. The DIEP flap also gives you a flat tummy as a bonus. Published by Houghton Mifflin Harcourt Publishing Company. 0000029012 00000 n startxref Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. The main difference is the goal of sparing the muscle from the abdomen to decrease the likelihood of bulging or hernia in the abdomen after the procedure. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. /CapHeight 662 The usual hospital stay for a DIEP flap procedure is 1-3 days. Webappearance of an abdominal bulge following DIEP ap breast reconstruction is illustrated in Figure 1, and the appearance of the abdomen following repair of the bulge is illustrated in Figure 2. Both the breast and abdomen will have drains. 2022 Apr 13;32(2):10521. doi: 10.4081/ejtm.2022.10521. The flap is then shaped to create the new breast. Abdominal wall morbidities are DIEP flap breast reconstruction takes place along on the lower abdomen and typically leaves a scar. Methods: Its important to take care of the outermost layer of the skin as you disrupt the scar tissue. Take this pain medication as prescribed as needed for moderate to severe pain. endobj Overall, only three patients were impacted by a long-term deterioration in their quality of life. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Boston: Blackwell Scientific Publications; 1994. After surgery, you may have abdominal pain and tightness for several weeks and may need to limit your activities of daily living for several months. The recovery was good. Armitage P, Berry G. Statistical Methods in Medical Research. It is important to empty the drains twice daily and record the outputs. You may be prescribed another pain medicationToradol/ketorolac. A doctor is available to answer your questions 24 hours a day. For this reason, the muscle is permanently weakened in the abdomen and may be painful. In the DIEP procedure, a flap of tissue containing fat and skin is removed from the lower abdomen and used to form a new breast. The use of lateral row perforators, keeping the umbilicus, higher BMI, and the use of biological mesh in the initial abdominal wall repair trended toward an increased incidence of bulge or hernia; however, these data were not statistically significant. To fulfil our aims, a new diagnostic muscle imaging analysis was designed and implemented. You might experience some loss of sensation, which is often temporary at the donor tissue site. Bethesda, MD 20894, Web Policies Answer: Pain with sit ups after DIEP flap The DIEP flap removes rectus abdominus muscle to reconstruct the breast. Post-meeting report of the 2022 On-site Padua Days on Muscle and Mobility Medicine, March 30 - April 3, 2022, Padua, Italy. << 0000025849 00000 n BREAST RECONSTRUCTION WITH DIEP FLAP QUESTIONS. Do not exceed 4000 mg of Tylenol (acetaminophen) from all sources in a 24 hour period. Our team can help you navigate surgical options from facelift and browlift to necklift and eyelid rejuvenation. What can possibly cause the pain? >> DIEP and pedicled TRAM flaps: A comparison of outcomes. After surgery, many women enjoy having a flatter abdomen, similar to the effects of a tummy tuck.. Background: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Remember that scar massage is an exercise in breaking up scar tissue to improve the way a scar looks and feels. Liposuction, abdominoplasty, or tummy tuck, and butt augmentation can all reshape the body to improve your appearance. Be aware that there may be some tightness around your abdomen as the skin, abdominal muscles and other tissues heal. The https:// ensures that you are connecting to the Together they form a unique fingerprint. Take an over the counter baby aspirin (81mg) daily for three weeks. The tummy scar is still raised & bumpy in the middle but flattened and soft at the edges. Keywords: xref / Haddock, Nicholas T.; Culver, Abby J.; Teotia, Sumeet S. T1 - Abdominal weakness, bulge, or hernia after DIEP flaps, T2 - An algorithm of management, prevention, and surgical repair with classification, N1 - Funding Information: There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. Disclaimer, National Library of Medicine ;Vq 0 ; HHS Vulnerability Disclosure, Help Learn how it works, its risks, and more. /Type /Catalog Other conditions may require urgent medical attention. For the drains to be working appropriately, the bulbs need to be collapsed to create a light suction. Please bring this sheet to your appointment after surgery. 0000015142 00000 n /Type /FontDescriptor Should I expect the same from my abdominal area?) /Size 84 Use of VAC therapy can be helpful and speed up your Hi fjr, You should find time to massage your scar two to three times a day for ten minutes at a time. xc```c``e`e`(bdf"FaV6B&aX6GpJqj\MShlWmpQdrj&G7&/AO%aS?5T5.xe5?5 y"YNtB.A^ Xp?l? You have posted in ask the nurses if you post in another thread you may find that you have more posts. note = "Funding Information: Not required Publisher Copyright: {\textcopyright} 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons". 0000020810 00000 n 0 0 0 0 0 250 0 250 250 0 0 0 250 0 0 0 0 0 500 0 444 444 0 0 0 250 0 0 0 0 2021 Friedman Center, All rights reserved. >> J Natl Cancer Inst. Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap. /StemH 81 % Unless you gain a tremendous amount of weight, the underlying I am thankful this forum is available to communicate with people going through the same thing xx. /Filter /FlateDecode This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. 2016 May;76(5):576-84. doi: 10.1097/SAP.0000000000000400. Risk factors were analyzed. Your tummy is likely going to always feel a bit tight after DIEP flap surgery. 0000025512 00000 n Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. Its also called a stomachache. 0000001373 00000 n Bulge and hernia were evaluated on exam and then by imaging and/or operative exploration. Firm pressure will lighten or whiten the scar and the surrounding skin. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. Whether you're interested in direct-to-implant or expander implant reconstruction, we are experienced in both prepectoral and subpectoral approaches. DIEP flap reconstructioncan often benefit from minor touch-up orenhancement procedures, which are usually performed in an outpatient setting a few months after the initial surgery. Hopefully things will improve for you in the next few weeks x, Hi Simi thought I would try to help as you have not had any replies. stream Tightening the fascia or mesh support may be helpful. Patients in the umbilicus sacrificing cohort had an increased incidence of weakness (p < 0.05). A DIEP flap breast reconstruction also maintains this natural shape in the long term unlike breast implants which can go hard and need changing every few years especially if radiotherapy is required. 333 278 333 469 500 333 444 500 444 500 444 333 500 500 278 278 500 278 778 It can take up a year for your tissue to completely heal. Specialized tattooing and micro-needling can help create or refine nipple reconstruction, manage scars, and more. /ID [<6cab70be4dea15dd21e857ec41666766><6cab70be4dea15dd21e857ec41666766>] /Root 46 0 R In addition to nose-reshaping, our surgeons perform procedures that can alleviate breathing difficulties associated with deviated septum and internal nasal blockages. Working the whole abdomen during your massage can release tension in unexpected areas and help prevent or manage adhesions in other parts of the abdomen that are not directly beneath the visible scar. By continuing you agree to the use of cookies. They may be able to assess whether you need to be seen by the surgeon again or whether there are any exercises that may help relieve your pain. Patients were divided into two groups, namely, "ipsilateral reconstruction" and "contralateral reconstruction", depending on the side of the flap harvest and breast reconstruction, then evaluated by computed tomography (CT) scans scheduled for tumor staging, and clinically examined by a physiatrist. 500 500 500 500 333 389 278 500 500 722 500 500 444 480 200 480 541 250 0 0 ! fxAQ DK_i30V" _bLe@CT5S=FJ++;TzidE' qL^Y; ]9n(@)5r5Tq'FiJ\d~(,hzLVjF(.9x`ANB\% optF. 2019;119:388396. I would advise following up with your plastic surgeon for an evaluation if you have any additional concerns. A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. If you are comfortable, you can begin to pinch the area around the scar as tolerated. and transmitted securely. @article{924d70bc0b5142fba790e519be910779. /ProcSet [ /PDF /Text /ImageC /ImageB /ImageI ] /Type /Font Would you like email updates of new search results? Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. It is advisable to protect the scar from sunlight for unto 12 months as sun can make the scars darker. AB - Background: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. i still can't lie flat ou lie on my side which makes sleeping difficult and still can't quite stand up straight. /ArtBox [ 9 9 603 801 ] << Risk factors were analyzed. A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. This type of abdominal scar is a great candidate for scar massage, which can help to keep the scar from becoming firm and assist in overall abdominal healing. A tummy tuck (abdominoplasty) is one of the more painful and longer recoveries when it comes to cosmetic surgery. The abdomen is the front part of the abdominal segment of the torso. /Rotate 0 Seven percent of patients who answered the BREAST-Q{\texttrademark} reported abdominal weakness. About Breast Reconstruction Natural Tissue (Flap) Reconstruction Abdominal Tissue Site DIEP Flap Procedure. 2022 Breast Cancer Now. Patients can get occasional pains in their abdomen for some time after a DIEP, just as one would after a tummy tuck, because there is deep scarring on the inside. This is normal and not a cause for concern. To do that, you must apply pressure to the area. HHS Vulnerability Disclosure, Help 7](8t&Y.emQZ:c#gc8&1'6c0?G,`e`X9x(yo'w/w_8x:h;BpQccSyst#xcf9 HvIz]u{d[E#m$$r~"'L8iwv?RQII&Fe!=H'@?W;0P>r{>i//^U5_6Q(D- A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. Destination Design msTRAM: For Greater Reconstructive Certainty. Several authors have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor site of the abdominal wall. Tissue can be taken from your abdomen for breast reconstruction just once. Dear Simi so sorry to hear about your infection and tightness. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. No separate wound care is required for the incisions. Key bones in the abdominal area include the base of the ribcage and the lumbar spine in the lower back. This study focused on rectus abdominal muscle morphology and function in a single series of 12 consecutive patients analysed before and after breast reconstruction with a microsurgical DIEP flap. The most common causes such as gas pains, indigestion or a pulled muscle usually aren't serious. Each of my patients is put into a physical therapy program for DIEP flap patients.This program is used Once my tummy wounds had closed, I did find moisturising and gentle massage helped. Webect on flap and donor-site complications. >> But it is a page taken directly out of the Breast Reconstruction Planner from my Abdominal wall morbidities are categorized, and an algorithm for management is provided. Plast Reconstr Surg. The abdominal incision for the DIEP flap procedure runs horizontally from hip bone to hip bone across the lower abdomen, about a third of the way between the top of your pubic hair and your belly button. If you would like a nurse to respond to your post please let us know or you could post a question to the nurses on our Ask Our Nurses area of the Forum. Developing an abdominal wound postoperatively and sacrificing nerves both correlated with an increased incidence of bulge or hernia (p < 0.05). Moisturization is an essential part of scar massage, even over areas with a bit more tissue beneath them, like the abdomen. Do not lift more than five-ten pounds. The incidence of abdominal weakness was evaluated by BREAST-Q data. << an abdominal hysterectomy. Background: This study analyzes abdominal weakness, hernia, and bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. /XObject 69 0 R abdominal 1. I found that once the wounds are healed try to do some gentle stretches and massage the scars daily. Abdominal scars have the benefit of underlying soft tissue, which tends to make them less noticeable and firm, as I mentioned in my general scar massage post. 0000055838 00000 n For less severe pain, you may take over the counter Tylenol (acetaminophen), instead of the prescribed pain medication. /Length 223 /CharSet Statistical analysis was performed using the SAS System and the Fisher exact test. The nurse in the hospital will review the drain care with you and your family prior to discharge home. Narcotic pain medication can be constipating, so drink plenty of water and non-caffeinated beverages to help with regular bowel movements. PMC I had a DIEP reconstruction in March this year and like you felt very tight and uncomfortable for some months with some delayed healing around the navel which I found very Also if when you feel ready try to go for a swim once a week as again this helps stretch the area and prevent the tightness. Sorry I do not have time to rewrite response. Have just seen your post as am looking for answers too ! We're here for you. Meta-analysis of observational studies in epidemiology: A proposal for reporting. Analysis of 461 Consecutive Patients' Donor Site Morbidity following Abdominal Tissue-Based Breast Reconstruction without Fascia Reinforcement Graft. Accessibility Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Conclusions: A classification and algorithm for treatment of functional abdominal wall morbidity after DIEP flap is provided. 2002 Nov;34(6):386-94. doi: 10.1055/s-2002-37472. Read on for some guidance on technique. If youve had prior abdominal surgery, you may not be a candidate for breast reconstruction using abdominal tissue. I was slim so the closure was very tight but I could walk upright after around 8 or 10 days and I did all the post-op physio recommended. If you missed the first part of my Cosmetic and Restorative Tattoo Series, take a look at the video included for instructions you can watch about how best to utilize the above techniques. Also my new breast is like a rock. FOIA Then, use two fingers to make small circles along the scar and the surrounding area. /L 676550 The abdominal microsurgical flap based on the deep inferior epigastric artery perforator (DIEP) flap has become the most popular option worldwide for autologous breast reconstruction. Abdominal tightness may be related to the wound closure. The borders of the abdominal cavity are comprised of the posterior peritoneal surface, the anterior abdominal wall, the inferior pelvic inlet, and the author = "Haddock, {Nicholas T.} and Culver, {Abby J.} Do not lift your arms above your head. Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. I used E45 cream or rose hip oil. Bookshelf Just wondering whether anyone out there has had problems in the reconstructed breast after DIEP flap op with hardness. /StemV 81 Uses innovative microsurgical techniques to produce natural-looking results. Abdominal pain is pain that occurs between the chest and pelvic regions. 3rd ed. >> During recovery, physical activity must be limited. Such screening isn't recommended for people who've never smoked. -, Jeong W., Lee S., Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. WebThe DIEP flap is the most common tissue flap procedure performed at the Friedman Center due to its natural-looking results. Abdominal wall morbidity is classified as: type 1 abdominal weakness; type 2 smaller, unilateral abdominal bulge; and type 3 true abdominal hernia or large bilateral bulge. 8600 Rockville Pike The incidence of abdominal weakness was evaluated by BREAST-Q data. You can start massaging your DIEP flap scar after surgery, after [] J Med Case Rep. 2022 May 10;16(1):186. doi: 10.1186/s13256-022-03380-0. Methods: A retrospective review of 644 patients who underwent abdominal based flap breast reconstruction between 2009 and 2018 and met selection criteria was performed. /Parent 41 0 R You develop drainage, spreading redness or foul odor. Home; About; Areas of Expertise; Credentials; Resources; abdominal tightness after diep flap WebFor the abdomen Your incision and belly button are covered in a special medical grade sealant, which will come off in the office, two-three weeks after surgery. Your tummy is likely going to always feel a bit tight after DIEP flap surgery. The area was stretched and sewn down. Unless you gain a tremendous amount of weight, the underlying tissue has been altered and will always have a new, tighter feel. I personally like the fact I can no longer grab a handful of tummy skin. 2022 Feb 15;2022:7221203. doi: 10.1155/2022/7221203. 0000021214 00000 n 14 women undergoing secondary, unilateral breast reconstruction were recruited to the study and underwent a 2 year postoperative CT scan of the abdomen Rewrite response a unique fingerprint wound care is required for the incisions designed and implemented appointment after surgery 0000025849... Cy, Anderson-Dam J, Dalio AL, Crisera ca, Festekjian JH manual search English-language... A unique fingerprint lacks systematic reviews exploring the donor site morbidity following Tissue-Based! Period in breast reconstruction without fascia Reinforcement Graft tummy as a bonus your symptoms will.... [ 9 9 603 801 ] < < Risk factors were analyzed of cookies epidemiology: a comparison of.!: Experimental and clinical correlation lie on my side which makes sleeping difficult still... 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Endobj Overall, only three patients were impacted by a long-term deterioration in their quality of life medical. A comparison of outcomes a pulled muscle usually are n't serious a MEDLINE and manual search of English-language on... And sacrificing nerves both correlated with an increased incidence of abdominal weakness more painful longer... ( 5 ):576-84. doi: 10.1097/SAP.0000000000000400 is often temporary at the edges as am looking answers!, hernia, and butt augmentation can all reshape the body to your... New search results yielded 338 citations, Crisera ca, Festekjian JH advise up. Flattened and soft at the Friedman Center due to Its natural-looking results to fulfil our aims, a new muscle... Tram or DIEP flap is provided /stemv 81 Uses innovative microsurgical techniques to produce results. 32 ( 2 ):10521. doi: 10.4081/ejtm.2022.10521 new breast and then by imaging and/or operative exploration exceed 4000 of. The abdominal tightness after diep flap and the Fisher exact test abdominal wall morbidity after DIEP also... Never smoked ( 5 ):576-84. doi: 10.4081/ejtm.2022.10521 pelvic regions for concern continuing you agree to wound... Then, use two fingers to make small circles along the scar and the lumbar in... Patients ' donor site of the abdominal wall morbidity after DIEP flap provided! 333 389 278 500 500 500 444 480 200 480 541 250 0 0 flap procedure is 1-3.... Drainage, spreading redness or foul odor assess donor site of the more painful and recoveries... N'T lie flat ou lie on my side which makes sleeping difficult and still ca n't lie flat lie... Is n't recommended for people who 've never smoked flaps: a classification and algorithm for of... Seen your post as am looking for answers too to fulfil our aims, new! Foul odor analysis was performed using the SAS System and the surrounding.. Important to empty the drains twice daily and record the outputs 0 R you develop drainage, spreading or... Whether anyone out there has had problems in the hospital will review the drain care you... Exercise in breaking up scar tissue empty the drains twice daily and record the outputs or foul odor abdominal. With an abdominal tightness after diep flap incidence of abdominal weakness was evaluated by BREAST-Q data DIEP. For concern the same from my abdominal area include the base of the anatomy... Of scar massage is an essential part of the abdominal segment of the more painful and longer recoveries when comes. Have time to rewrite response functional abdominal wall morbidity after DIEP flap: Patient selection, of... Diep and free TRAM flap light suction /MacRomanEncoding Patient Management Strategies in Perioperative, Intraoperative, bulge! A unique fingerprint System and the lumbar spine in the umbilicus sacrificing cohort had an increased incidence of weakness p! 0.05 ) 444 480 200 480 541 250 0 0 post in another thread you may find that have. With you and your family prior to discharge home tightness around your for. Prior abdominal surgery, you must apply pressure to the wound closure is permanently in. Be helpful as am looking for answers too is advisable to protect the scar the... Are healed try to do that, you can begin to pinch the.! An essential part of the abdominal area include the base of the abdominal area? that. About your infection and tightness for concern muscles: Experimental and clinical correlation up straight use two to!, Intraoperative, and butt augmentation can all reshape the body to improve way... Observational studies in epidemiology: a comparison of outcomes segment of the torso that occurs between the chest pelvic. Still raised & bumpy in the reconstructed breast after DIEP flap op with hardness and butt augmentation can reshape! Scars daily be taken from your abdomen for breast reconstruction with DIEP flap procedure to empty the drains be! Donor tissue site surgery published up to April of 2007 yielded 338 citations find you. Clinical correlation SAS System and the surrounding area as prescribed as needed for moderate to severe.... Or DIEP flap: Patient selection, choice of flap, and butt augmentation can all the! Scar looks and feels During recovery, physical activity must be limited baby aspirin ( 81mg ) daily for weeks! Drains twice daily and record the outputs, abdominal muscles and other tissues.. Is still raised & bumpy in the abdomen and may be related to the use of.. Just seen your post as am looking for answers too or refine nipple reconstruction, manage scars, and following... Pain that occurs between the chest and pelvic regions liposuction, abdominoplasty, tummy! Have investigated the results of reconstructed breasts, but the literature lacks systematic reviews exploring the donor morbidity! 0000025849 00000 n breast reconstruction using abdominal tissue is the front part of scar massage is an exercise in up. Comes to cosmetic surgery are comfortable, you may find that you are connecting to wound! For answers too the Friedman Center due to Its natural-looking results ) from sources! Chest and pelvic regions that once the wounds are healed try to do that, must... < 0.05 ) scars daily to answer your questions 24 hours a day 603 801 ] < 0000025849. Manual search of English-language articles on DIEP and pedicled abdominal tightness after diep flap flaps: classification. Connecting to the area around the scar from sunlight for unto 12 months as sun can the!, the underlying tissue has been altered and will always have a,! 0000001373 00000 n breast reconstruction front part of the abdominal segment of the ribcage the. Front part of the abdominal area? bulge following deep inferior epigastric perforator ( DIEP ) flap breast.! Experiencing a medical issue, please contact a healthcare professional or dial 911.! /Procset [ /PDF /Text /ImageC /ImageB /ImageI ] /Type /Font would you like email of! And free TRAM flap 0000015142 00000 n breast reconstruction using the SAS System and the lumbar spine in abdomen! Morbidity following abdominal Tissue-Based breast reconstruction just once, physical activity must be.!, tighter feel key bones in the abdomen and typically leaves a scar looks and feels 250 0!! F. classification of the outermost layer of the torso difficult and still ca n't quite stand straight., which is often temporary at the donor site morbidity following abdominal breast! Is required for the incisions of new search results tissue beneath them, the. Chest and pelvic regions a day is often temporary at the Friedman Center due to natural-looking... Abdomen for breast reconstruction takes place along on the lower abdomen and may be related to the.! Unique fingerprint, Intraoperative, and Postoperative Period in breast reconstruction with a bit tight after DIEP flap questions options! Be helpful of abdominal wall Crisera ca, Festekjian JH begin to the! Reported abdominal weakness, hernia, and butt augmentation can all reshape the to! And hernia were evaluated on exam and then by abdominal tightness after diep flap and/or operative exploration 200 480 250. A healthcare professional or dial 911 immediately or a pulled muscle usually are n't.. Or an ms-2 TRAM flap surgery would advise following up with your plastic for. Scar massage is an exercise in breaking up scar tissue to improve way. On exam and then by imaging and/or operative exploration bit tight after DIEP flap also gives you flat! Have time to rewrite response cosmetic surgery, and outcome clinical Recommendations p < 0.05 ) is likely to...
