The term "flap" means that a surgeon takes healthy tissue from another area of a woman's body for use in reconstruction. The deep inferior epigastric artery is the blood vessel that goes through the abdomen and provides the blood supply to the tissue of the lower abdomen.
Several different breast reconstruction options exist. A DIEP flap reconstruction is often performed in phases for the reconstructed breasts to look as natural as possible.
- A DIEP flap involves taking excess skin and fat from the stomach to reconstruct the breast.
- DIEP flap surgery requires specialized microsurgery training and is highly complex.
- The DIEP flap is one of several evolving approaches to breast reconstruction surgery.
What is the reconstruction process?
Microsurgery is required for the DIEP flap breast reconstruction process.
The DIEP flap reconstruction process requires specialized training in a field of medicine known as microsurgery.
Microsurgery involves the use of small, specialized instruments to operate on delicate areas of tissue, such as nerves and blood vessels.
It is called microsurgery because the blood vessels are usually less than 3 millimeters in size, and either a microscope or special operating eyeglasses called loupes are required to perform the surgery.
A microsurgery procedure takes anywhere from 4-8 hours for one flap and up to 24 hours for a bilateral flap reconstruction.
DIEP flap procedure
The procedure involves making an incision in the abdomen, usually from one hipbone to the other. The scar from it will usually be below the "bikini line."
When doctors are performing a one-side reconstruction, they will use the skin from one side of the abdomen. If both breasts are being reconstructed, they will use tissue from both sides.
Once this tissue is removed, a doctor will remove the lower abdominal tissue with the artery and vein, and then close the remaining abdominal skin, usually more tightly than before. They will then use the removed tissue to create a new breast.
Often, a small part of a rib near the middle of the chest is removed so that the surgeon can connect the abdominal tissue to an artery and a vein in the chest. On other occasions, the transplanted tissue is connected to blood vessels in the armpit.
Usually, the surgeon will not reconstruct the nipple or areola portion of the breast at the time of the DIEP flap surgery. They may have to revise the breast surgery to continue re-shaping the breast. Only when the breast tissue has fully healed will the surgeon perform the areola reconstruction.
Advantages of DIEP flap reconstruction
The DIEP flap is a newer, more complex version of a TRAM flap or Transverse Rectus Abdominus Myocutaneous flap.
In the TRAM flap procedure, the skin and fat of the lower abdomen were removed, as well as one or both of the rectus or "sit-up" muscles.
Eventually, the TRAM flap procedure was refined to the DIEP flap, where very little or no muscle is removed, leaving a person with fewer core strength problems.
This switch in surgeries can also result in shorter recovery times associated with the DIEP flap approach, and a lesser chance of a hernia or bulge of the abdomen after surgery.
Whether a person undergoes a free TRAM or DIEP flap, the incisions appear the same. The results are often compared to those of a tummy tuck.
DIEP flap recovery
According to Johns Hopkins Medicine, a woman will stay in the hospital an estimated 3 to 4 days after her DIEP flap procedure. However, some women may require a longer recovery time in hospital.
How soon can you walk?
Women are usually encouraged to do some gentle physical activity, such as walking, on the second day after their surgery.
A woman will have three to four surgical drains in place when she is discharged from hospital. The drains can help prevent the tissue from becoming swollen and will usually stay in place 1 to 2 weeks.
A doctor will show a woman how to empty the drains, or a home health nurse will visit to empty them for her.
How long does the recovery take?
Most women can resume regular activities about 4 to 6 weeks after surgery.
The most significant part of the recovery is the soreness associated with the abdominal incisions, as most activities use the core muscles of the body in this area for movement.
A woman should wait before driving or resuming other more strenuous activities until she receives clearance from her doctor.
Complications and risks
The DIEP flap can be a good option for many people. However, there are risks associated with this complicated surgical approach, including:
- poor healing
- hernia or bulge
- flap loss
A woman may experience problems with circulation within the newly connected tissue, a complication known as flap loss. This can cause the newly implanted tissue to die, and it will usually require surgical removal.
Is DIEP flap the best approach?
The DIEP flap is an evolving approach to breast reconstruction surgery and the tissue used can only be taken once from another location.
Several other techniques exist for breast reconstruction, using the tissue from a woman's own body.
In addition to the DIEP or TRAM flaps, the alternatives include:
- SGAP flap: This procedure a superior gluteal artery perforator flap, which involves taking skin and fat from the buttock to reconstruct the breast.
- Latissimus dorsi flap: This technique involves using fat, muscle, and tissue from a woman's back to reconstruct her breast. The tissue is strategically removed with the blood supply remaining intact, and it is rotated from the back to the breast.
Some people prefer these approaches as they also do not involve inserting an artificial implant into the skin, and they use a woman's own tissue.
Regardless of the surgical approach, a woman may want to consider that tissue can be taken only once from another location for reconstruction.
Therefore, if a woman is contemplating prophylactic mastectomy, to prevent her cancer spreading to her other breast, and she desires a DIEP flap or other reconstruction approach, her doctor may advise that she waits to perform reconstruction on both breasts.
Furthermore, some women may not be able to have a DIEP flap procedure due to previous abdominal surgery. Or they may have other health considerations that can preclude these options.
Similarly, surgeons may sometimes consider that a woman does not have enough abdominal tissue to reconstruct a breast. And her blood vessels may be too small to reconnect the tissue successfully.
Lastly, women who use tobacco are likely to be asked to quit smoking, as they are more likely to have problems with healing of their incisions.
Conclusions on the DIEP flap
Though there are many advantages to the DIEP flat, not all hospitals and facilities offer the option because of its newness, and because it requires specialized training and instruments
A woman should discuss her reconstruction options with her doctor and evaluate if it is what she wants and if she is a suitable candidate for the procedure.