A mastectomy, the surgical removal of breast tissue often necessary for breast cancer treatment, leaves many patients seeking reconstruction options. While breast implants are a common choice, many patients prefer autologous reconstruction, using their own natural tissue for a softer, more permanent result. The Deep Inferior Epigastric Perforator (DIEP) flap procedure is an advanced technique available in this area. This complex surgery creates a new breast mound using tissue from elsewhere on the body, offering an alternative that looks and feels more like natural breast tissue.
Defining DIEP Flap Breast Reconstruction
The DIEP flap procedure is a sophisticated form of autologous breast reconstruction that uses skin and fat from the patient’s lower abdomen. DIEP stands for Deep Inferior Epigastric Perforator, which names the specific blood vessels that supply the transferred tissue. A perforator is a small blood vessel that travels through muscle to supply the overlying skin and fat.
The core benefit of the DIEP flap is its muscle-sparing nature, a major advancement over older techniques like the Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Unlike the TRAM flap, which requires removing a portion of the rectus abdominis muscle, the DIEP procedure meticulously preserves this abdominal muscle. By leaving the muscle intact, the risk of abdominal wall weakness, bulging, and hernia is significantly reduced.
The tissue flap, including skin, fat, and the perforator blood vessels, is completely detached from its original location, classifying it as a “free flap.” This flap must then be reconnected to a new blood supply in the chest area using microsurgery. This delicate reconnection makes the DIEP procedure a technically demanding operation performed only by surgeons with specific training in microvascular surgery.
The Surgical Process
The DIEP flap procedure is a lengthy operation, often taking four to six hours or more, involving two distinct surgical sites: the chest and the abdomen. The surgery begins with the preparation of both the recipient site on the chest wall and the donor site in the lower abdomen. The surgeon makes an incision in the lower abdomen, typically running from hip to hip, to harvest the tissue flap.
The most time-intensive part is the dissection of the perforator blood vessels that supply the abdominal tissue. The surgeon must carefully separate these tiny vessels as they pass through the rectus abdominis muscle without damaging the muscle itself. This involves tracing the perforator back to its source, the deep inferior epigastric artery and vein, and isolating the pedicle—the main artery and vein that will supply the flap.
Once the skin, fat, and attached pedicle are removed as a free flap, the tissue is transferred to the chest area. The micro-surgical phase involves connecting the flap’s artery and vein to recipient vessels in the chest, such as branches of the internal mammary vessels. This connection, known as anastomosis, requires an operating microscope and specialized instruments to ensure blood flow is immediately restored to the transferred tissue.
After successful revascularization, the abdominal tissue is shaped and sculpted to create a breast mound, and the incision is closed. The abdominal donor site is closed in a way that resembles a tummy tuck, resulting in a tightened, contoured lower abdomen and a scar that runs horizontally across the lower belly.
Determining Patient Candidacy
Suitability for DIEP flap surgery depends on a patient’s body composition and overall medical history. The primary physical requirement is having sufficient excess skin and fat in the lower abdomen to create a breast of the desired size. Even patients with a low Body Mass Index (BMI) may still be candidates, provided the necessary tissue volume is present.
Previous abdominal surgeries are a major consideration because they may have compromised the deep inferior epigastric blood vessels required for the flap. While common procedures like C-sections, hysterectomies, or tubal ligations often do not interfere with the necessary vessels, prior extensive abdominal surgery, such as a full tummy tuck or a traditional TRAM flap, may make a patient ineligible. Imaging studies, such as a CT angiogram, are frequently used before surgery to map the location and health of the perforator vessels.
General health also plays a significant role, as this is a major micro-surgical procedure. Conditions that affect blood flow and healing, such as uncontrolled diabetes or severe chronic heart disease, increase the surgical risk. Patients are strongly advised to cease smoking, as nicotine severely constricts blood vessels, which can compromise the blood supply to the free flap and increase the risk of tissue loss.
Post-Operative Recovery and Long-Term Results
Following the DIEP flap procedure, patients typically have a hospital stay ranging from two to seven days while the reconstructed breast is monitored for adequate blood flow. Surgical drains are placed at both the breast and abdominal sites to collect excess fluid, and these are usually removed days to a few weeks after surgery. Initial recovery involves soreness and tightness in both the chest and abdomen, and patients are often advised to walk slightly bent over for the first few days to protect the abdominal incision.
Activity restrictions are important for the first six to eight weeks, requiring strict avoidance of heavy lifting (over 10 pounds). The full healing process, including the fading of swelling and bruising, can take several months, with the body continuing to settle for up to a year. The long-term outcome is a reconstructed breast made of warm, soft tissue that feels more natural than an implant and will age along with the rest of the patient’s body.
A significant long-term benefit of using living tissue is that the breast does not require replacement surgeries, unlike implants. The donor site results in a flat, contoured abdomen with a horizontal scar placed low enough to be concealed by underwear, similar to an abdominoplasty. While the initial reconstruction provides the volume and shape, patients may choose to have secondary procedures later, such as fat grafting or nipple-areola reconstruction, to refine the aesthetic result.