Once it is determined during consultation that you are in fact a candidate for an autologous tissue flap to be harvested from your abdomen, the rest is up to your internal anatomy. Dr Small always first dissects out the Superficial Inferior Epigastric Arteries to evaluate their suitability for a flap to be based on them. Although the literature states that around 10-15% of patiens are candidates for the SIEA procedure, in fact, much fewer that that are safe candidates. We have found the flap to be much less reliable than a DIEP and better suited when the breast to be reconstriucted is very small. Dr. Small then explores the perforating vessels of the Deep Inferior Epigastric Artery. Those vessels are much beter suited for reconstruction ona regular basis. Rarely, usually when there has been prior gynecologic surgery, a free muscle sparing TRAM is performed if their is concern about the ability of the vessels to support the flap.
It is basically a factor of blood supply. The operation that is performed (DIEP vs SIEA vs Free TRAM) is the operation with the best blood supply to prevent fat necrosis with the least toll on the abdomen.