What Is DIEP Flap Breast Reconstruction?

What to expect when undergoing this procedure

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Deep inferior epigastric artery perforator (DIEP) flap is one of the most common breast reconstruction procedures done after a mastectomy (breast removal surgery).  

If you are having this procedure, your surgeon will remove skin and fat from your abdomen and move them up to your chest wall 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.

DIEP is a free flap procedure that reconnects the blood vessels taken from the abdomen tissue to the chest. Microvascular surgery reattaches the blood vessels in the new location to provide a good blood flow for the flap to heal in place.

This article discusses DIEP flap breast reconstruction including the purpose, risks, contraindications, surgical procedure, and recovery.

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

Purpose of Procedure

With this method, skin and fat are removed from the belly to create a new breast. The donor tissue is typically taken from below the belly button (umbilicus) and above the pubic hair. It is similar to a transverse rectus abdominus myocutaneous (TRAM) flap, though the TRAM procedure also uses muscle from the abdomen.

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 slightly increase.

Surgical risks include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Surgical site infection
  • Wound healing difficulties
  • Seroma (fluid build-up), with pain and swelling in the breast or the donor site
  • Problems with the new connections of the vein or artery that lead to flap failure

Because your donor site does not have skin similar to a nipple, you and your surgeon may decide on:

  • Nipple-sparing surgery
  • Immediately creation of a reconstructed nipple during surgery
  • Delay and placement of a nipple later

Your new breast and nipple may have decreased sensation. However, sensory changes and recovery vary by person and are hard to fully predict. You can speak to your plastic surgeon regarding nerve reconstruction techniques that can be used along with the DIEP to regain sensation.

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

In general, DIEP is a safe and effective option for reconstruction.

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 is not 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 out of bed and encourage you to move around. 
  • While rare, necrosis (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 signs are detected immediately.

This surgery has low overall complication rates, with a retrospective study in 2020 showing less than 1% total flap loss.

Contraindications

This procedure is not right for everyone.

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

  • You are thin: If you are 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 thighs.
  • 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: Smokers have much higher rates of surgical complications with DIEP flaps. If you are able to stop smoking six weeks prior to surgery, your surgeon may OK the procedure. That said, a history of smoking may rule this option out for you, especially if you have vascular disease.

Before the Surgery

If you are thinking about reconstruction, it can be 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 your reconstruction may guide your breast surgeon to save as much skin as is safe during your mastectomy and prevent unnecessary scars.

Ask your surgeons all of your questions and ask them to show you before and after photos of women who have had a DIEP flap. You may also ask to speak to women who have had the surgery for other insights about their experience.

Be sure to tell your anesthesiologist if you have had a bad reaction to any type of anesthesia in the past, so they 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.

Timing

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

If you need radiation therapy to your underarm area or chest, your healthcare providers will recommend that you wait until your radiation therapy is complete. Having breast reconstruction done before radiation can severely limit the effectiveness of the treatment in certain circumstances.

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. Your medical team will work with you to get the necessary appointments. However, ultimately, following your insurance rules is your responsibility, so be sure to ask questions along the way.

What to Bring

Make sure to bring your identification and insurance card, any relevant paperwork or test results, and your regular medications or medication list.

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 opens in the front (buttons or zipper) and will not 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.

During Surgery

You will be asked to arrive at the hospital up to two hours before 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.

DIEP flap surgery traditionally takes six to eight hours. However, the exact timing will depend on how complicated your surgery is.

Pre-Surgery

You will not be awake during your surgery, 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 release 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.
  • The DIEP blood vessels will be disconnected from their original location.
  • 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 (stitched) 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 the same position through a new hole created by your surgeon. The top and bottom areas from the donor site will be stretched so they can be joined together. The incision area for the flap donor site will leave a scar that goes all the way across your stomach from one hip bone to the other; this is similar to a tummy-tuck scar.

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.

After Surgery

After your surgery, you will go to the recovery room, where you will 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 initial recovery.

If you have surgical drains, you will 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 if needed.

Recovery

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 location.

You can expect to have bruising and swelling in both your breast and your stomach. 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. If possible, make plans to have someone around to drive and lift any heavy objects for you. 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 is 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

Summary

DIEP is a common surgery for breast reconstruction after breast cancer surgery. This procedure involves moving skin and fat from the lower abdomen to the chest, and reattaching the blood vessels to the new area with microsurgery. Your medical team will discuss the risks, contraindications, how to prepare, and what to expect given your individual circumstances.

A Word From Verywell

Breast reconstruction after a mastectomy is a personal choice. 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 benefits and risks.

Your decision on which to opt for—if you choose to have reconstruction—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 decide on DIEP reconstruction.

Frequently Asked Questions

  • Is DIEP flap the same as a tummy tuck?

    DIEP flap and a tummy tuck use a similar incision below the belly button and between the hip bones to remove skin and fat. However, they are not the same.

    For a DIEP flat for breast reconstruction, the focus is on safely removing the extra tissue to use it to create a new breast mound, so the surgeon pays special attention to saving the blood vessels in the tissue that's removed.

  • How much fat do you need for a DIEP flap?

    The amount of fat and skin needed for a DIEP flap depends on several factors, including the amount of skin remaining on your chest wall after mastectomy and the desired size of the breast after reconstruction. Your surgeon will examine your body and discuss your options for donor sites.

  • Is a DIEP flap permanent?

    A DIEP flap is generally permanent. A surgeon can make some modifications to help improve the final appearance, and a nipple and areola can typically be added if desired. If the blood supply fails or the breast mound tissue dies, a revision may be required.

10 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.
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  3. American Cancer Society. What to expect after breast reconstruction.

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Additional Reading
Originally written by
Pam Stephan
Pam Stephan is a breast cancer survivor.
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