What Is DIEP Flap Breast Reconstruction?

What to expect when undergoing this procedure

Deep inferior epigastric artery perforator (DIEP) flap is one of the most common breast reconstruction procedures done after a mastectomy. The DIEP flap procedure uses skin and tissue (no muscle) from the abdomen to create a new breast mound. This procedure is a form of autologous reconstruction, which is a type of surgery that uses your own tissue for reconstruction.

Surgeon Beginning Procedure With Scalpel In Hand, Close-up
Dureuil Philippe / Getty Images

Purpose of Procedure

With this method, skin and tissue are removed from the belly to create a new breast. It is similar to a transverse rectus abdominus myocutaneous (TRAM) flap, though the TRAM procedure also uses muscle from the abdomen.

DIEP reconstruction typically requires three stages to complete the reconstruction.

Risks and Contraindications

Research published in 2017 shows that DIEP flap surgery is safe and the risk for complications is low. When both breasts are reconstructed, the risks increase.

Risks include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Surgical site infection
  • Wound healing difficulties
  • Fluid build-up, with pain and swelling in the breast or the donor site
  • Problems with the new connections of the vein or artery

Your new breast and nipple may have decreased sensation. The sensation takes close to two years to return, and in some instances, it will not. You can speak to your plastic surgeon regarding nerve reconstruction techniques that can be used along with the DIEP to regain sensation.

The operation leaves two surgical sites and scars—one where the tissue was taken from and one on the reconstructed breast. The scars fade over time, but they won't ever go away completely.

You can only have abdominal tissue removed one time. If you need another breast reconstruction, you and your surgeon will have to talk about other methods. For some people, the removal of abdominal tissue results in a tummy tuck, giving them a flatter stomach.

Complications

Some potential complications may require medical or surgical intervention.

  • Fluid and blood accumulation in the new breast is usually absorbed by the body. If it isn't absorbed, your healthcare provider may need to drain the fluid.
  • There is a risk of developing postoperative blood clots in your legs or your lungs. To prevent this, your nurses will help you get up right away and encourage you to move around. 
  • While rare, tissue death can affect a small number of people who have a DIEP flap surgery. Tissue death is a result of a failed new blood supply. Often this can be surgically fixed if it's noticed immediately.

Contraindications

This procedure isn't right for everyone.

You might not be a good candidate for the DIEP procedure if:

  • You're thin: If you're very thin or have had abdominal tissue removed before, you may not have enough donor tissue for the procedure. If that is the case, you may be able to have a different type of reconstructive procedure that uses tissue from areas such as the back, buttocks, or thigh.
  • You have/are at risk for vascular issues: Healthy blood vessels and adequate blood supply are necessary for the survival of the transplanted tissue, so flap procedures may not be successful for women who have uncontrolled diabetes, vascular disease, or connective tissue diseases like rheumatoid arthritis and scleroderma.
  • You smoke: If you are able to stop smoking six weeks prior to surgery, your surgeon may OK the procedure. That said, smoking may rule this option out for you, especially if you have vascular disease.

Before the Surgery

If you are thinking about reconstruction, it's helpful to see your plastic surgeon before undergoing a mastectomy. They will work with your breast surgeon to plan the surgical treatments and reconstruction surgeries for your unique situation. 

Your plastic surgeon can take precise measurements and pictures of your breasts before your mastectomy to help make your reconstructed breast(s) as close to your natural shape and size as possible.

Planning the reconstruction in advance may guide your breast surgeon to save as much skin as is safe during your mastectomy and prevent unnecessary scars.

Ask your surgeons questions regarding preparing for surgery, postoperative course, and risks and complications they have had. Ask them to show you photos of women who've had a DIEP flap. You may also want to speak to women who've had the surgery for other insights.

Be sure to mention if you have had a bad reaction to any type of anesthesia in the past, so your anesthesiologist can determine which medications would be safe for you.

Choosing the Right Surgeon

A DIEP flap involves careful microsurgery to reconnect blood vessels. ​This requires extensive training and experience. Choose a surgeon for this reconstruction carefully. Ask plenty of questions until you feel comfortable making a decision to go ahead with the procedure.

Timing

Breast reconstruction can be done during a mastectomy (immediate reconstruction) or after treatment.

If you need radiation therapy to your underarm area or chest, your doctors will recommend that you wait until your radiation therapy is complete. Having the procedure done before radiation severely limits the effectiveness of the treatment.

DIEP flap surgery takes six to eight hours. You'll be required to stay in the hospital for several days afterward.

Location

DIEP flap surgery is performed in the operating room of a hospital.

Food and Drink

Follow any instructions your surgeon provides regarding preparation for the procedure. This may include diet, medications, and quitting smoking. Typically, you will be asked not to eat or drink anything for eight to 12 hours before your surgery.

Cost and Health Insurance

Breast reconstruction is costly, running well into the tens of thousands of dollars. Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction.

Medicare covers breast reconstruction, but Medicaid coverage can vary from state to state.

If you are insured, check with your plan provider to find out what your costs will be. Some people may face high deductibles or co-payments. Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures.

Some insurance companies require a second opinion before they will agree to pay for surgery.

What to Bring

Hospitals often provide basic items for your stay, but you may want to bring some of your own things for familiarity and comfort.

Consider packing:

  • Comfortable pajamas (loose-fitting is best) and a robe
  • An outfit to wear home that won’t rub on your incision
  • A pillow and soft blanket (also useful for your ride home)

Do not bring valuable personal items, such as jewelry, cash, or electronics, and remember your regular medications, insurance card, and any relevant paperwork.

During Surgery

You will be asked to arrive at the hospital up to two hours prior to your surgery. A nurse or other healthcare provider will check your vital signs and have you change into a surgical gown and possibly a cap as well. You will also be given a hospital ID bracelet.

Pre-Surgery

You will not be awake during your mastectomy or reconstruction, and you will have intravenous sedation or general anesthesia.

Throughout the Surgery

After your anesthesia is started, your plastic surgeon will mark your skin for the tissue flap incision. Using a skin marker, they will draw a semi-elliptical section across your stomach, just below your navel and above your pubic area.

  • The surgeon will make the incision and raise a layer of skin and fat.
  • When disconnecting this tissue flap, they will include the deep inferior epigastric perforator artery and vein that will bring a dependable blood supply to your new breast. These blood vessels will be carefully preserved along with the tissue flap.
  • No abdominal muscle will be cut or moved during this process.
  • Your tissue flap, complete with blood vessels, will be moved to your mastectomy area.
  • In order to maximize tissue survival in its new location, your surgeon will use a high-power microscope to reattach the blood vessels in the tissue flap to blood vessels in your chest. The sutures used are about the same diameter as a strand of your hair, so great precision is needed.
  • The skin and fat tissue are then carefully reshaped into a breast mound and sutured into place.

Most women have enough extra tissue in their tummy area to create a new breast. If not, a small implant can be placed under your tissue flap to create the breast size that you want.

Your navel will remain in position above the abdominal incision. The incision for the flap will leave a scar that goes all the way across your stomach.

The surgeon may use skin marking techniques over the blood vessels to help your nurses monitor healing as you recover. Expect to have ​surgical drains placed in your incision to help with healing.

Post-Surgery

After your surgery, you will go to the recovery room, where you'll stay until the anesthesia has worn off and your vital signs are stable. You will then move to a regular room at the hospital. Expect to stay in the hospital for three to five days following a DIEP flap procedure.

Blood flow to the flap will be closely monitored during your recovery.

If you have surgical drains, you'll be taught how to empty them and to keep track of the fluid volume before you are discharged. You will also be given a prescription for painkillers.

After the Surgery

A DIEP procedure involves incisions in two different locations, so your recovery may take longer and can be more difficult for you than surgery in only one surgical location.

You can expect to have bruising and swelling in both areas; your healthcare provider will likely have you wear compression garments to reduce the swelling. It may be challenging at first to find a position that does not put pressure on your chest area or abdomen. Over time, the tenderness in those areas will subside.

Plan on resting for four to six weeks. Make plans to have someone around to drive and lift any heavy objects for you, if possible. Your healthcare provider will advise you on when you can resume bathing, exercise, and sexual activity.

You will have several follow-up appointments so your surgeon can assess your healing progress and incisions, and change your dressings.

When to Call Your Healthcare Provider

While you are healing, it's especially important to be aware of signs of infection. Call your healthcare provider right away if you experience:

  • Redness, pain, blood, or pus around your incisions or the surgical drain insertion site
  • Surgical drain fluid containing blood or pus after a few days
  • Fever
  • Pain that is worsening instead of improving over time
  • Your breast becomes purple or swollen

These could be signs of another surgery-related complication that requires evaluation:

  • A painful, red, swollen leg that may be warm to touch
  • Breathlessness
  • Pain in your chest or upper back
  • Coughing up blood

A Word From Verywell

Breast reconstruction after a mastectomy is a personal choice. It is not medically necessary, but it may help your well-being, quality of life, and overall outlook. In addition to DIEP flap reconstruction, there are other options for reconstruction, and each one comes with its own benefits and risks. Your decision on which to opt for will depend on personal preferences, your overall health, and other factors. Make sure you discuss all the pros and cons of the various options with your surgeon before you make a decision on DIEP reconstruction.

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5 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Johns Hopkins Medicine. Deep Inferior Epigastric Artery Perforator (DIEP) Flap.

  2. Wade RG, Razzano S, Sassoon EM, Haywood RM, Ali RS, Figus A. Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions. Ann Surg Oncol. 2017;24(6):1465-1474. doi:10.1245/s10434-017-5807-5

  3. Breastcancer.org. DIEP Flap Surgery Risks.

  4. American Cancer Society. What to Expect After Breast Reconstruction Surgery.

  5. Fayanju OM, Garvey PB, Karuturi MS, Hunt KK, Bedrosian I. Surgical Procedures for Advanced Local and Regional Malignancies of the BreastThe Breast. 2018. doi:10.1016/b978-0-323-35955-9.00059-3.

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