Breast Reconstruction: The DIEP Flap

An interview with Jason J. Rosenberg, M.D.

New advances in breast cancer reconstruction and recent additions to the staff at the Plastic Surgery Center of The Orthopaedic Institute have enabled us to offer the widest possible range of reconstructive options to our patients with breast cancer and breast diseases. A popular choice among women seeking breast reconstruction is the deep inferior epigastric-artery perforator (DIEP) flap. Combining the benefits of using one’s own abdominal skin and fat while minimizing damage to the abdominal musculature, the DIEP flap offers an excellent option for a natural appearing breast reconstruction in the appropriate patient.

Who is a candidate for a DIEP flap reconstruction?

Patients who are diagnosed with breast cancer or breast disease requiring a mastectomy may be a candidate for reconstruction. A DIEP may be performed either at the same time as the breast removal (mastectomy) or at some time after the mastectomy has been completed and healing of the tissues has occurred.

Deciding which is the best type of breast reconstruction requires an examination of the patient’s body type, need for certain types of cancer treatment (chemotherapy and/or radiation therapy), and individual factors that the patient brings into the equation. A discussion with a board-certified plastic surgeon who is trained in all methods of breast reconstruction will offer the patient the most choices for a reconstruction tailored to their individual needs.

The DIEP flap reconstruction is best suited to patients who are seeking the most natural type of breast reconstruction and have an active lifestyle in which abdominal muscle strength is an important consideration for the patient.

Why is a DIEP preferable to breast implant reconstruction?

Breast implants are a common method of breast reconstruction used by many plastic surgeons. In patients who have not had radiation therapy to treat their breast cancer and who have had both breasts removed (bilateral mastectomy), implant based reconstruction can be a very good choice. However, it is often difficult to match the remaining breast with implant reconstruction alone. Simply put, a natural breast does not look like a breast implant.

The DIEP flap enables the surgeon to use the natural tissue of the patient’s abdomen and, by transplanting this tissue to the chest, recreate a natural appearing breast mound. While breast implants can get infected requiring their removal, deflate, or become hardened with time, these do not occur with natural tissue reconstruction of the DIEP flap.

How does the DIEP flap compare to the TRAM flap?

The Transverse Rectus-Abdominus Myocutaneous (TRAM) flap uses the patient’s skin and abdominal fat to recreate the breast. This flap, however, requires the surgeon to cut through the entire abdominal muscle on one side of the abdomen in order to supply blood to the tissues used for reconstruction. The circulation to this flap is not as strong as the DIEP flap and may result in melting away of some of the flap often referred to as fat necrosis. Also, the loss of the abdominal muscle may result in weakness of one side of the abdomen or even a hernia.

In contrast, the DIEP flap allows the surgeon to spare the abdominal muscle. To do this, the surgeon carefully separates the small blood vessels that supply the skin and fat from abdominal muscles resulting in minimal disruption to abdominal strength and integrity. In this procedure, risks of abdominal hernia or bulge are decreased as compared with the TRAM flap. The blood supply to the DIEP flap, in the appropriate candidate, is better than the TRAM flap resulting in a more stable and reliable long-term result.

What are the risks of DIEP flap breast reconstruction?

All surgeries carry with them certain risks. Bleeding, infection, differences between the reconstruction and remaining breast are common to many types of breast reconstruction. Implant-based techniques have complications of implant loss, deflation, and hardening of the implants. The TRAM flap has the risks associated with abdominal weakness and a bulge where the muscle is rotated onto the chest.

The DIEP flap also carries with it some potential complications. The tissue transplanted to the chest requires the use of microsurgical techniques to sew together the very small blood vessels that provide circulation to the transplanted tissue. In rare cases (1-3%) the blood vessels may become clotted resulting in loss of the flap and need for a backup procedure for breast reconstruction. The risks and benefits of any operation, including the DIEP flap, are dependent upon certain factors unique to each individual patient. The best way to determine these factors is through a consultation with a board certified plastic surgeon that specializes in breast cancer reconstruction.