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, a surgery that uses your own tissue.

Purpose of Procedure

A DIEP flap is done for aesthetic reasons and is a voluntary procedure.

With this method, skin and tissue are removed from the belly to create the new breast. It is similar to a TRAM flap, though the TRAM procedure uses muscle from the abdomen as well.

While some women only undergo a DIEP flap reconstruction, others opt to have additional reconstructive surgery to create the appearance of a ​nipple and areola.

Risks and Contraindications

Research shows that DIEP flap surgery is safe and the risk for complications is low. When both breasts are reconstructed, however, the risks increase. Risks of any surgery, which apply here, include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up with pain and swelling (in this case, in the breast or donor site, i.e., where the flap was removed)

More specifically related to the DIEP flap procedure itself, you should expect:

  • Loss of sensation: Your new breast and nipple will not have much if any sensation because the nerves that were in your original breast have been removed. You may regain some sensation as the severed nerves grow and regenerate, but this is not guaranteed. Breast surgeons continue to make technical advances that can spare or repair damage to nerves, but there's more work to be done.
  • Scarring: 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.

Your surgeon can remove abdominal tissue only one time. If you need another breast reconstruction, you'll have to choose a different method. (In some women, the removal of abdominal tissue results in a tummy tuck, giving them a flatter stomach.)

Complications

Fluid and blood accumulation in the new breast is usually absorbed by the body. In some cases, however, your doctor may need to drain the fluid.

In addition, you are at risk for blood clots in your legs or your lungs post-surgery. To prevent this, nurses will get you up right away and encourage you to move around. 

While rare, tissue rejection can affect a small number of people who have a DIEP flap surgery. Tissue rejection is called tissue necrosis, which means the entire flap has failed. If this happens, the dead tissue flap will be removed and surgery can be re-attempted in six to 12 months.

Contraindications

You are unlikely to 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 critical to the survival of the transplanted tissue, so flap procedures may not be the best options 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 the surgery, your surgeon may OK the procedure. That said, smoking may rule this option out for you due to vascular health concerns.

Before the Surgery

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

Consultations give you the chance to have precise measurements and pictures taken of your natural breasts. A plastic surgeon will use this information to make your reconstructed breast(s) as close to your natural shape and size as possible. It also allows your doctors to work to save as much skin as is safe during mastectomy and prevent unnecessary scars.

Ask whatever questions you have at this time and ask to see pictures of other women who've had a DIEP flap. You may also want to ask to speak to women who've had the surgery.

Be sure to mention if you have had a bad reaction to any type of anesthesia in the past, so the anesthesiologist can be informed in advance and can come up with an alternative. Some people experience allergic reactions, nausea, or breathing problems with certain anesthetics.

Choosing the Right Surgeon

A DIEP flap involves careful microsurgery to reconnect blood vessels—the most critical part of the procedure. ​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 the underarm area or chest, it makes sense to wait. Having the procedure done before radiation is complete 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 thereafter.

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 information on diet, medications, and quitting smoking. Typically, you will be asked not to eat or drink anything for eight to 12 hours before the 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. If you are insured, check with your plan provider to find out what your costs will be.

Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider. However, in other non-immediate or delayed cancer cases, it could take up to six weeks for finalization.

This surgery can be expensive; some people may face high deductibles or co-payments. Some insurance companies require a second opinion before they will agree to pay for surgery.

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

What to Bring

Hospitals often provide basic items for your stay, but you may want to bring some of your own things to provide a sense of familiarity and comfort to the sterile hospital surroundings. In particular, 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, so you will have intravenous sedation or general anesthesia. Talk to your surgeon and the anesthesiologist about which will work best for you.

Throughout the Surgery

Once you have received anesthesia, your plastic surgeon will mark your skin to carefully plan for the tissue flap incision. Using a skin marker, he will draw a semi-elliptical section across your stomach, just below your navel and above your pubic area. When the incision for the flap is shut, it will leave a scar that goes all the way across your stomach.

The surgeon will make the incision and raise a layer of skin and fat. Before disconnecting this tissue flap, they will search for 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. Your navel will remain in position above the incision.

No abdominal muscle will be cut or moved during this process. 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 tissue flap, complete with blood vessels, will be moved up to your mastectomy area. In order to ensure the tissue will survive in its new location, the 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.

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 to begin healing. Blood flow to the flap is critical and will be closely monitored.

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

Expect to stay in the hospital for about five days following a DIEP flap procedure.

After the Surgery

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

You can expect to have bruising and swelling in both areas; your doctor 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 doctor 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 Doctor

While you are healing, it's especially important to be aware of signs of infection. Call your doctor 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

Likewise, these could be signs of another surgery-related complication and warrant 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 you manage your emotional and physiological well-being, life quality, and overall outlook. In addition to DIEP flap reconstruction, there are other options, 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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