A deep inferior epigastric artery perforator (DIEP) flap is a type of breast reconstruction procedure. Healthcare providers may offer this procedure after a mastectomy, or the surgical removal of one or both breasts due to breast cancer.
After a mastectomy, a plastic surgeon may reconstruct the breast(s) to reduce the psychological impact of the surgery.
Several different breast reconstruction options are available. These tend to take place at the time of the mastectomy or after recovery.
During DIEP flap reconstruction surgery, a surgeon will take healthy tissue, skin, and fat from the person’s lower abdomen to use in breast reconstruction.
The deep inferior epigastric artery is the blood vessel that runs through the abdomen and provides blood to the tissue of the lower abdomen.
A surgeon may perform DIEP flap reconstruction in several phases so that the reconstructed breasts look as natural as possible.
In this article, we explain how the process works, its advantages, and some possible complications that might develop following surgery.
The DIEP flap reconstruction process requires specialized training in a field of medicine called microsurgery.
It is a type of breast reconstruction known as autologous surgery. This means that a surgeon uses tissue from other parts of the body to complete the reconstruction.
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 under 3 millimeters in size. A surgeon will require either a microscope or special operating eyeglasses called loupes to perform the surgery.
A microsurgery procedure can take anywhere from 4 to 8 hours for a single flap and up to 24 hours for a flap reconstruction on both breasts.
During the procedure, the surgeon will make an incision in the abdomen, usually from one hip bone to the other.
When surgeons perform reconstruction on one breast, they will use the skin from one side of the abdomen. If the surgery affects both breasts, the procedure will involve tissue from both sides of the abdomen.
After the removal of the tissue from this area, the surgeon will excise the lower abdominal tissue with the artery and vein. After this, they close the remaining abdominal skin, usually more tightly than before.
This removed tissue then serves as the material to create the new breast(s).
The surgeon will often remove a small part of a rib near the middle of the chest. They do this so that they can attach the abdominal tissue to an artery and a vein in the chest. On other occasions, the surgeon may connect the transplanted tissue 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 tend to only perform the areola reconstruction once the tissue has fully healed.
The DIEP flap surgery is a newer and more complex version of a transverse rectus abdominus myocutaneous (TRAM) flap.
In the TRAM flap procedure, a surgeon will remove the skin and fat of the lower abdomen and from one or both of the rectus muscles, which support sitting upright.
Over time, surgeons refined the TRAM flap procedure into the DIEP flap, which involves the removal of little to no muscle. This causes fewer core strength problems after the procedure.
The DIEP flap procedure also results in shorter recovery times and comes with a lower risk of a hernia after surgery.
Whether a person has TRAM or DIEP flap surgery, the incisions have a similar appearance and may resemble those of a tummy tuck.
According to breastcancer.org, a person who undergoes a DIEP flap will stay in the hospital for around 5 days. However, some people may need to stay longer to support recovery.
How soon can you walk?
A doctor will usually encourage a person to engage in gentle physical activity, such as walking, on the second day following surgery.
A person will have three to four surgical drains in place after their discharge from the hospital. The drains can help prevent the tissue from becoming swollen and will usually stay in the body for 1–2 weeks.
A healthcare provider will usually show a person how to empty these drains. Alternatively, a home health nurse will visit to empty them.
How long does recovery take?
Most people can resume their regular activities about 6–8 weeks after surgery.
Often, the most challenging part of the recovery process is the soreness from the abdominal incisions. This is because most activities involving movement use the core muscles in this area.
People should wait until a doctor gives clearance before driving or resuming more strenuous activities.
Complications and risks
The DIEP flap can be a good option for many people who have undergone mastectomy. It can help reduce the psychological impact of losing one or both breasts.
However, this complicated surgical approach carries its own risks, including:
- poor healing
- flap loss, in which a person experiences problems with circulation within the newly connected tissue
Flap loss can cause the newly implanted tissue to die and will usually require surgical removal.
Some alternatives to the DIEP flap include:
- Superior gluteal artery perforator flap: This procedure involves taking skin and fat from the buttock to reconstruct the breast.
- Latissimus dorsi flap: This technique uses fat, muscle, and tissue from the back to reconstruct a breast. A surgeon strategically removes tissue while leaving the blood supply intact and rotates this tissue from the back to the breast.
Some people prefer these approaches, as they do not require the insertion of an artificial implant into the skin.
Regardless of the approach, people considering breast reconstruction should note that a surgeon can only take tissue once from another location.
A person may be thinking about a prophylactic mastectomy to prevent the spread of cancer from one breast to the other. If they wish to have a DIEP flap or an alternative approach, their doctor may advise waiting to perform reconstruction on both breasts.
Some people may not be able to have a DIEP flap procedure, such as those who have had previous abdominal surgeries or have other health considerations.
Surgeons sometimes conclude that a person does not have enough abdominal tissue to receive a DIEP flap. Their blood vessels may also be too small to reconnect the tissue successfully.
A doctor will most likely ask people who use tobacco to quit smoking. Smoking tobacco is likely to interfere with the healing of the incisions.
DIEP flap reconstruction surgery has many advantages over other types of breast reconstruction.
However, not all hospitals and facilities offer the option, as it is a new procedure that requires specialized training and instruments.
A person considering this type of surgery should discuss their reconstruction options with a doctor and evaluate the risks and benefits. The doctor will determine whether they are a suitable candidate for the procedure.
Do I need a breast reconstruction after a mastectomy?
Breast reconstruction after mastectomy is completely optional.
Although there is no functional benefit to having breast reconstruction, people who do undergo immediate reconstruction tend to have better body image perceptions in the early postoperative period than those who do not.
However, the difference in body image does not seem to last beyond 1 year, and scores comparing the groups tend to be the same after that.