DIEP Flap

This natural tissue reconstruction option uses tissue from the abdomen to create a breast.

Summary

The DIEP flap is the most common form of natural tissue breast reconstruction. It uses perforator surgery and microsurgical techniques to create a breast using skin and fat from a patient’s own lower abdomen. The flap includes blood vessels which are transplanted to the chest wall.

DIEP flap breast reconstruction works well for women who have adequate skin and fat in the lower abdomen. It is ideal for those who would like to avoid or are poor candidates for breast implants, like women who have undergone radiation therapy prior to reconstruction.

Doctors use imaging tests, like CT angiograms, to help determine whether a patient’s lower abdomen has the necessary blood supply before surgery. During the procedure, surgeons expose these small blood vessels, transfer them to the mastectomy site, and connect them to the blood vessels in the chest.

Types of DIEP Flap procedures

DIEP flap

The blood supply for this flap comes from the deep inferior epigastric perforator vessels that pierce the rectus muscle. Perforator surgery techniques make it possible to tease these vessels out of the rectus muscle without compromising its function.

DTI split plane

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Immediate DIEP flap after skin-sparing mastectomy – flap skin replaces the missing nipple areola. The nipple can be reconstructed at a second stage.

diep flap IMF approach

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Immediate DIEP flap after nipple-sparing mastectomy – incision can frequently be hidden along the lower breast.

SIEA flap

This approach avoids deep incisions through the muscle by using the superficial inferior epigastric vessels to feed the flap. These vessels are not available or large enough to use in most patients. When they are available, this approach avoids any incisions through the muscles when harvesting and transferring the flap. 
siea flap illustration

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TRAM free flap

Some patients require a small portion of rectus muscle to carry the lower abdominal wall tissue’s blood supply. This is a transverse rectus abdominis myocutaneous free flap.

tram free flap skin island

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Immediate TRAM free flap after skin-sparing mastectomy – flap skin replaces the missing nipple areola, and the abdomen where a portion of muscle was removed may be repaired with mesh. The nipple can be reconstructed at a second stage.
tram free flap IMF approach

© Image Credit

Immediate TRAM free flap after nipple-sparing mastectomy – incision can frequently be hidden along the lower breast. The abdomen where a portion of muscle was removed may be repaired with mesh.

Procedure details:

  • CT angiogram before surgery maps the lower abdominal vessels and helps predict which vessels can be used for the flap
  • Surgeons remove a large ellipse of skin and fat from the lower abdomen. The blood vessels needed to support the flap are selected at that time.
  • The flap is transplanted to the chest and used to create a breast shape.
  • After flap transfer, any incisions in the rectus muscle are repaired.
  • The abdomen is closed in a way that is similar to a tummy tuck.

Risks & Benefits

These flaps are microsurgical free flaps, which means that small blood vessels are connected to transplant tissue from one part of the body to another. This creates a risk of problems with flap blood supply after surgery. Should problems with blood supply arise, you may require additional surgery to complete the breast reconstruction.

When a surgeon is trained and experienced in microsurgery, this risk of issues with blood supply is very small. It is critical to choose a plastic surgeon with experience in microsurgery.

The main benefit of an abdominal flap is that it provides a warm, soft breast reconstruction from living tissue. It also avoids the need for a breast implant, and it improves the shape of the abdomen in some patients.