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Breast Reconstruction: DIEP Flap

What is DIEP flap reconstruction?

Key points

  1. A DIEP flap is a technique that can be done after mastectomy to surgically reconstruct a breast.
  2. It uses skin, fat, and blood vessels taken from your abdomen to form the breast.
  3. A DIEP flap is usually not medically necessary, but discussing the pros and cons of all surgical and nonsurgical options with your doctor can help you decide what’s right for you.

A deep inferior epigastric artery perforator (DIEP) flap is a procedure done to surgically reconstruct a breast using your own tissue after a mastectomy. A mastectomy is surgery to remove the breast, usually performed as part of breast cancer treatment. A surgeon can perform reconstruction surgery during or after a mastectomy.

There are two ways to perform breast reconstruction. One way is to use natural tissue taken from another part of the body. This is known as autologous reconstruction. Another way is to use breast implants.

There are two major types of autologous breast reconstructive surgery. They are called DIEP flap and TRAM flap. The TRAM flap uses muscle, skin, and fat from your lower abdomen to construct a new breast. DIEP flap is a newer, more refined technique that uses skin, fat, and blood vessels taken from your abdomen. DIEP stands for “deep inferior epigastric artery perforator.” Unlike a TRAM flap, the DIEP flap preserves the abdominal muscles and allows you to maintain strength and muscle function in your abdomen. This also leads to a less painful and faster recovery.

Here’s what you need to know about how the reconstruction works, its benefits and risks, and what you can expect if you opt for a DIEP flap.

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Candidates

Who is a candidate for a DIEP flap reconstruction?

An ideal candidate for a DIEP flap is someone with enough abdominal tissue who isn’t obese and doesn’t smoke. If you’ve had a previous abdominal surgery, you may not be a candidate for a DIEP flap reconstruction.

These factors can put you at high risk for complications after a DIEP reconstruction. You and your doctor can discuss possible alternatives if you’re not a candidate for a DIEP reconstruction.

Timing

When should I get a DIEP flap reconstruction?

If you’re a candidate for a DIEP flap, you may have reconstructive breast surgery at the time of your mastectomy or months to many years later.

More and more women are opting to have immediate breast reconstructive surgery. In some cases you will need a tissue expander to make room for the new tissue. A tissue expander is a medical technique or device that is inserted to expand the surrounding tissue, helping to prepare the area for further surgery. It will be expanded gradually to stretch the muscles and breast skin to create room for the reconstructive tissue.

If you need to use tissue expanders before reconstructive surgery, the reconstruction phase will be delayed. Your surgeon will place the tissue expander during the mastectomy.

Chemotherapy and radiation will also affect the timing of DIEP flap breast reconstruction. You will have to wait four to six weeks after chemotherapy and six to 12 months after radiation to have your DIEP reconstruction.

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Surgery

What happens during the DIEP flap reconstruction?

A DIEP flap reconstruction is a major surgery that takes place under general anesthesia. Your surgeon will begin by making an incision across your lower abdomen. Then, they will loosen and remove a flap of skin, fat, and blood vessels from your abdomen.

The surgeon will transfer the removed flap to your chest to create a breast mound. If you’re having reconstruction on only one breast, the surgeon will try to match the size and shape of your other breast as closely as possible. Your surgeon will then connect the flap’s blood supply to the tiny blood vessels behind the breastbone or under the arm. In some cases it will be desirable to have a breast lift or reduction on the opposite breast to help ensure breast symmetry.

After your surgeon shapes the tissue into a new breast and connects it to the blood supply, they’ll close the incisions in your new breast and abdomen with stitches. The DIEP flap reconstruction can take as long as eight to 12 hours to complete. The length of time depends on whether your surgeon performs the reconstruction at the same time as a mastectomy or later in a separate surgery. It also depends on whether you are having surgery on one breast or both.

Benefits

What are the benefits of the DIEP flap reconstruction?

Preserves muscle integrity

Other breast reconstruction techniques that remove muscle tissue from your abdomen, such as the TRAM flap, increase your risk of abdominal bulges and hernia. A hernia is when an organ pushes through a weak part of the muscle or tissue that’s supposed to keep it in place.

DIEP flap surgery, however, doesn’t usually involve muscle. This may result in a shorter recovery time and less pain after surgery. Because the abdominal muscles are not used you will not lose abdominal strength and muscle integrity. You’re also at a much lower risk of developing a hernia.

Uses your own tissue

Your reconstructed breast will look more natural because it’s made from your own tissue. You also won’t need to worry about risks that come with artificial implants.

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Complications

What are the complications associated with the DIEP flap surgery?

All surgery comes with the risk of infection, bleeding, and side effects of anesthesia. Breast reconstruction is no exception. If you are considering this surgery, it’s important to have it done by a surgeon who has extensive training and experience in microsurgery.

Lumps: DIEP flap breast reconstruction can lead to breast fat lumps. These lumps are made up of scar tissue known as fat necrosis. The scar tissue develops if some of the fat in the breast isn’t getting enough blood. These lumps may be uncomfortable and may need to be removed surgically.  

Fluid buildup: There is also a risk of fluid or blood accumulating after surgery in the new breast. If this occurs, the body may naturally absorb the fluid. Other times, the fluid will have to be drained.

Loss of sensation: The new breast will not have normal sensation. Some women may regain some sensation over time, but many do not.

Issues with blood supply: About 1 in 10 people who undergo a DIEP flap reconstruction will experience flaps that have issues getting enough blood in the first two days after surgery. This is an urgent medical situation and will require surgery.

Tissue rejection: Out of 100 people who have a DIEP flap, about 3 to 5 people will develop complete rejection or tissue death. This is called tissue necrosis, and it means that the whole flap fails. In this case, your doctor will move forward with removing the dead flap tissue. If this happens it is possible to try the surgery again after six to 12 months.

Scars: The DIEP flap reconstruction will also cause scars around your breasts and belly button. The abdominal scar will likely be below your bikini line, stretching from hipbone to hipbone. Sometimes these scars can develop keloids, or overgrown scar tissue.

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Recovery

What happens after the DIEP flap reconstruction?

You will likely have to spend a few days in the hospital after this surgery. You’ll have some tubes in your chest to drain fluids. Your doctor will remove the drains when the amount of fluid decreases to an acceptable level, usually within a week or two. You may be able to resume normal activities within six to twelve weeks.

You can also have surgery to add a nipple or areola to your new breast. Your surgeon will want to let your new breast heal before reconstructing the nipple and areola. This surgery isn’t as complex as the DIEP flap reconstruction. Your doctor can create a nipple and areola using your own body tissue. Another option is to have a nipple and areola tattooed onto your new breast. In some cases, your surgeon can do a nipple-sparing mastectomy. In this case, your own nipple may be preserved.

DIEP flap surgery can create a condition called contralateral breast ptosis, also known as drooping breast. Initially or over time, your original breast may droop in a way that the reconstructed breast doesn’t. This will give your breasts an asymmetrical shape. If this bothers you, speak to your doctor about correcting this. This can be done at the same time as your initial reconstruction or later with another surgery in the noncancerous breast.

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Takeaway

How to decide if you should have a breast reconstruction

Deciding whether or not to have breast reconstruction after a mastectomy is a very personal choice. Though it isn’t medically necessary, some women find that having breast reconstruction surgery improves their psychological well-being and quality of life.

There are several different reconstruction options, and each type comes with its own benefits and risks. A variety of factors will determine the surgery that is most appropriate for you. These factors include:

  • personal preference
  • other medical problems
  • your weight and amount of abdominal tissue or fat
  • previous abdominal surgeries
  • your general health

Make sure to discuss the pros and cons of all surgical and nonsurgical options with your medical team before making any decisions.

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