DIEP (Deep Inferior Epigastric artery Perforator) flap breast reconstruction uses a patient's own abdominal skin and fat to reconstruct a breast after mastectomy. DIEP refers to the blood vessel that supplies the skin and subcutaneous tissue of the lower abdomen, similar to the TRAM flap procedure. This is the same area of abdominal tissue that is discarded in patients that undergo cosmetic surgery for a "tummy tuck." However, unlike the TRAM flap procedure, the DIEP flap does not include any muscle in the flap. Instead, it is "perforator flap" meaning that it is supplied by blood vessels that travel within and through the abdominal muscle (the rectus abdominus).
The DIEP flap is moved to the chest (during surgery) for breast reconstruction by reattaching the circulation, i.e.blood vessels connections, and transferring skin flaps from one area of the body to the chest. By giving the tissue circulation, it can remain soft and feel more like a normal breast. Because it is technically more complex than implant and TRAM flap surgery, it should only be perforemed in medical centers that routinely perform microsurgery.
Potential advantages of DIEP flap reconstruction may include:
- Preservation of the abdominal muscle. People are less likely to experience abdominal muscle weakness, hernia or bulge post-operatively (though these side effects are still possible).
- Preservation of the protective sheath over the muscle
- Less post-operative pain compared to the TRAM flap procedure because the muscle is left in place and muscle fibers are gently spread apart to find the blood vessels that supply the flap.
Potential disadvantages of DIEP flap reconstruction may include:
- The DIEP flap can only be performed by reconstructive microsurgeons who have special training and experience.
- Time in the operating room for DIEP flap surgery is 4-5 hours for a single ("unilateral") reconstruction, and up to 8-10 hours for a "bilateral" reconstruction (both sides). The time of surgery can be increased by 1 to 2 hours if the reconstruction is immediate (done at the same time as the mastectomy).
- The DIEP flap is a "free flap" and involves "microsurgery." Microsurgery is surgery that is performed under the operating microscope. The flap tissue from the abdomen is isolated on its "microvascular pedicle" (one artery and one or two veins that bring blood supply to and from the tissue). The pedicle is isolated and then divided, cutting off the blood supply to the floap. The flap is then transferred to the chest area and the blood vessels are reconnected (the "microvascular anastomosis") in the chest region. With microsurgery, there is a small (3-5%) risk of failure of the vessel connection. If the blood vessels were to fail or clot off, a return to the operating room would be necessary to redo the connection (anastomosis) and to reestablish blood supply to the flap. While the risk of both flap procudre failure is low, the failure rate of the TRAM is significantly less than the DIEP flap (.1-2%).
- The hospital stay ranges from 3 to 5 days on average, depending on the speed of recovery and postoperative pain. This is in comparison to 1 to 2 days in the hospital for an implant reconstruction.
- The recovery time following a DIEP flap is longer than after an implant reconstruction. Generally, physically strenuous activities (running, aerobic activity, lifting more than 5 pounds) are to be avoided for 4-6 weeks after surgery. However, walking and light activities begin in the hospital, and should continue at home following discharge from the hospital.
- Blood loss is usually minimal, but in a bilateral reconstruction, and together with a mastectomy, a blood transfusion may be required. Autogenous blood donation (donating 1-2 units of your own blood beofre surgery) may be arranged up to 3 weeks before a bilateral reconstruction.
DIEP is not widely available, but good candidates for the procedure include healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound. Often, women have excess abdominal skin and fat following pregnancy and also benefit from the tummy tuck closure. In addition, radiation of the breast prior to reconstruction or anticipated radiation following surgery is another indication for the DIEP flap procedure.
Smokers, patients with diabetes or blood clotting problems are not good candidates for microsurgery. Patients who have had a previous abdominoplasty, a previous TRAM or DIEP flap, do not have the tissue available for reconstruction using the abdonminal akin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap procedure.