DIEP flap reconstruction

A DIEP flap is similar to a muscle-sparing free TRAM flap, except that no muscle is used to rebuild the breast. A DIEP flap is considered a muscle-sparing type of flap. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen.

In a DIEP flap, fat, skin, and blood vessels (but no muscle at all) are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because no muscle is used, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to any of the TRAM flap procedures.

Because the DIEP flap procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can do a DIEP flap and it’s not available at all hospitals. If you’re considering a DIEP flap, you may have to research the surgeons and facilities that offer what you want. Your doctor may be able to refer you to plastic surgeons who specialize in DIEP flap reconstruction.

Tissue can be taken from your belly for breast reconstruction only once. So if you’re thinking about prophylactic removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. If you have DIEP flap reconstruction on one breast and then later need reconstruction on your other breast, tissue for the second, later reconstruction will have to come from your buttocks or back. Or you can have reconstruction with an implant.

Because skin, fat, and blood vessels are moved from the belly to the chest, having a DIEP flap means your belly will be flatter and tighter – as if you had a tummy tuck. Still, a DIEP flap does leave a long horizontal scar — from hipbone to hipbone – about halfway between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, your navel may be in the wrong place or distorted in some way, so your surgeon may have to reshape your belly button.

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While DIEP flap breast reconstruction is popular because it doesn’t move muscle (which usually means a shorter recovery time than a TRAM flap), a DIEP flap isn’t for everyone. It’s not a good choice for:

Thin women who don't have enough extra belly tissue

Women who smoke

Women who already have had multiple abdominal surgeries

Women who plan on getting pregnant

WHAT TO EXPECT

During DIEP flap surgery, an incision is made along your bikini line and a portion of skin, fat, and blood vessels is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape. No muscle is moved in a DIEP flap.

The tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope.

DIEP flap reconstruction surgery takes about 6 to 8 hours

AFTER SURGERY

For a DIEP flap, you usually stay in the hospital for about 5 days. After that it can take about 6 to 8 weeks to recover from the surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you’ve had surgery at two sites on your body (your chest and your belly), you might feel worse than someone having mastectomy alone and it will probably take you longer to recover. You’ll likely have to take care of three incisions: on your breast, your lower abdomen, and around your belly button, and you’ll probably have drains in your reconstructed breast and in your abdominal donor site. If you had axillary nodes removed during this surgery, you’ll have a fourth incision under your arm.

As with any abdominal surgery, you may find that it’s difficult or painful to sit down or get. It’s important to take the time you need to heal. Follow your doctor’s advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after DIEP flap reconstruction.

It sometimes takes as long as a year or more for your tissue to completely heal and for your scars to fade.

RISKS

Like all surgery, DIEP flap surgery has some risks. Many of the risks associated with DIEP flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to DIEP flap reconstruction.

Tissue breakdown

In rare instances, the tissue moved from your belly to your breast area won’t get enough blood after the vessels are reattached and some of the tissue might die. Doctors call this tissue breakdown necrosis. Some symptoms of tissue necrosis include pain and bleeding, the skin turning dark blue or black, numbness, and sores that ooze a bad-smelling discharge or pus. You also may run a fever or feel sick. If this happens, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia.

Lumps in the reconstructed breast

If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don’t go away on their own, it’s best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.

Hernia or muscle weakness at the donor site

A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias happen in the abdomen. They usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy.

If you have a DIEP flap, you have a small risk of hernia. Your risk of hernia is much lower with a DIEP flap than with any type of TRAM flap. This is because a DIEP flap uses no muscle to rebuild your breast. Still, after any abdominal surgery, there is some risk of hernia.

Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically repairing the opening in the muscle wall. The surgery is generally done on an outpatient basis.