DIEP Flap Breast Reconstruction

DIEP flap breast reconstruction is a type of autologous (using the patient’s own tissue) breast reconstruction that uses skin and fat from the lower abdomen to reconstruct the breast after a mastectomy. DIEP stands for Deep Inferior Epigastric Perforator, which refers to the blood vessels used in the procedure. Here’s a detailed explanation of the DIEP flap procedure:

What is DIEP Flap Breast Reconstruction?

The DIEP flap procedure involves transferring skin, fat, and blood vessels from the lower abdomen to the chest to create a new breast. Unlike the older TRAM flap procedure, which also uses abdominal tissue, the DIEP flap preserves the abdominal muscles, reducing the risk of abdominal weakness and hernias.

The Procedure

1. Preoperative Planning:
   • Consultation: The patient meets with the plastic surgeon to discuss goals, expectations, and the surgical plan.
   • Imaging: Preoperative imaging, such as a CT angiogram, may be used to map the blood vessels in the abdomen.
2. Surgery:
   • Anesthesia: The patient is placed under general anesthesia.  DIEP flap breast reconstruction typically takes 6-8 hours to perform.
   • Harvesting the Flap: The surgeon makes an incision in the lower abdomen, similar to a tummy tuck incision, and carefully dissects the skin and fat, along with the deep inferior epigastric perforator blood vessels.
   • Preserving Muscles: The abdominal muscles are preserved, which helps maintain abdominal strength and reduces recovery time.
   • Transferring the Tissue: The harvested tissue (flap) is then transplanted to the chest, where the mastectomy was performed.  A small section of rib may be removed to access the vessels the flap is connected to.
   • Microvascular Surgery: The surgeon uses microsurgery techniques to connect the blood vessels of the flap to the blood vessels in the chest, ensuring a good blood supply to the transplanted tissue.
   • Shaping the Breast: The flap is shaped to create a natural-looking breast mound. The abdominal incision is then closed, often resulting in a flatter, tighter abdomen.
3. Postoperative Care:
   • Hospital Stay: Patients typically stay two nights in the hospital for monitoring the transplanted tissue.  An ERAS (Enhanced Recovery After Surgery) protocol is used to help expedite your recovery.
   • Drainage Tubes: Drainage tubes may be placed to remove excess fluid and are usually removed after a week or two.
   • Follow-Up Visits: Regular follow-up visits are necessary to monitor healing and address any complications.

Benefits of DIEP Flap Reconstruction

• Natural Look and Feel: The reconstructed breast has a more natural look and feel compared to implants.
• Muscle Preservation: By preserving the abdominal muscles, there is less risk of abdominal weakness and hernias.
• Dual Benefit: The procedure can provide the added benefit of a flatter abdomen, similar to a tummy tuck.
• Long-Lasting Results: Tissue-based breast reconstruction is the only permanent form of reconstruction.  Since the reconstruction uses the patient’s own tissue, the results can be long-lasting and change naturally with the body over time.

Risks and Considerations

• Surgical Complexity: The procedure is complex and requires a skilled microvascular surgeon.  Ask your surgeon if he/she has additional fellowship training in Reconstructive Microvascular Surgery and is board-certified by the American Board of Plastic Surgery.
• Longer Surgery and Recovery Time: Surgery typically takes several hours, and recovery can be longer compared to implant-based reconstruction.
• Potential Complications: These include flap failure (if the blood supply to the tissue is compromised), infection, seroma (fluid collection), and delayed wound healing.  If the vascular supply to your flap is found to be compromised during your hospital stay, you may need to return to the operating room urgently to save the flap.  Of note:
  • Take back rates for free flap breast reconstruction generally range from about 5% to 15 %.  In specialized, high-volume centers with experienced microsurgeons, the take back rate can be lower, often in the range of 5% to 10%
  • The overall flap failure rate for free flap breast reconstruction is relatively low, typically ranging from 1% to 5%.
• Scarring: There will be scars both on the abdomen and the reconstructed breast, though these typically fade over time.
• Revision Surgery (“Phase 2”): “Phase 2” of DIEP flap breast reconstruction typically refers to a secondary surgery performed after the initial reconstruction to refine the results and improve the overall aesthetic outcome. This phase is usually less extensive than the initial procedure and focuses on enhancing the appearance and symmetry of the reconstructed breast(s).  Please see the “DIEP Flap Breast Reconstruction: Phase 2” handout for details.

Ideal Candidates

• Good Health: Candidates should be in good overall health and able to tolerate a lengthy surgery.
• Sufficient Abdominal Tissue: Patients should have enough extra tissue in the lower abdomen to create the new breast.  However, a small implant may be used to supplement tissue volume to optimize results.
• Non-Smokers: Smoking can impair healing and increase the risk of complications, so non-smokers or those willing to quit are preferred candidates.

DIEP flap breast reconstruction is a sophisticated and effective method for creating a natural-looking breast using the patient’s own tissue. It is important for patients to discuss all options, potential risks, and benefits with their surgeon to determine the best approach for their individual situation.