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FAQs about DIEP Flap Breast Reconstruction after Mastectomy

Breast reconstruction after mastectomy has increased dramatically over the past 30 years. In fact, the trend for immediate breast reconstruction after mastectomy, performed at the same time the patient is in the operating room, has grown from 10% in the 1980s to about 90% today.

DIEP breast reconstruction (DIEP, pronounced "deep," stands for deep inferior epigastric perforators, which are blood vessels) is a reconstructive procedure that represents one of the most advanced forms of breast reconstruction now available. The surgery uses the patient's own abdominal skin and fat to reconstruct a natural, warm, soft breast after mastectomy.

The DIEP flap procedure preserves all the abdominal muscles. Only abdominal skin and fat are removed similar to a tummy tuck. Patients experience less pain after surgery because of this, enjoy a faster recovery, and maintain their abdominal strength long-term.

Because of the complexity of the surgery, few breast centers offer DIEP flap breast reconstruction despite the many advantages the procedure offers patients.

Here, our director of breast reconstruction, Duc T. Bui, MD, associate professor of surgery and member of our Plastic and Reconstructive Surgery Division, answers frequently asked questions about breast reconstruction and the DIEP flap procedure.

Q: What are the advantages to having breast reconstruction after mastectomy?

A: The goals of breast reconstruction are to restore the breast shape, size, and appearance to near normal and to achieve breast symmetry when dressed. It eliminates the need for external prosthesis. Many studies have shown that breast reconstruction patients have improved quality of life and psychosocial well-being.

Q: What is a "flap" with regard to breast reconstruction?

A: A flap is tissue taken from your body with its blood supply used to reconstruct the breast. The flap can be pedicled (meaning that the blood supply stays attached to the body) and transferred up to the chest or free (meaning that the blood supply is disconnected and transferred up to the chest and reconnected again with microsurgery). Common flaps for breast reconstruction are the TRAM flap (tissue taken from the abdomen) and the latissimus flap (tissue taken from the back).

Breast Reconstruction: What You Should Know
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Q: What is a DIEP flap?

A: A TRAM flap (transverse rectus abdominis myocutaneous) flap consists of skin, fat, rectus muscle, and blood vessels taken from the abdominal wall and transferred to the chest to reconstruct the breast. Initially, it was pedicled flap, then with the advent of microsurgery, it became a free flap. A DIEP flap is similar to a TRAM flap but the muscle is spared. It consists of skin, fat, and blood vessels only. The blood vessels are dissected from the rectus muscle.

Q: What are the advantages to DIEP flap breast reconstruction?

A: The rectus muscle is not taken, thus less pain, and risk of abdominal weakness or hernia, hence quicker recovery.

Q: How do I know if I am a candidate for a DIEP flap breast reconstruction? Does weight or age make a difference?

A: If you have enough lower abdominal soft tissue, then you are a candidate for a DIEP flap. The more weight you have, the more likely you have enough lower abdominal soft tissue. Age usually does not make a difference.

Q: Where do the skin and other tissue come from for natural-tissue breast reconstruction?

A: Other options include back (latissimus flap), buttock (gluteal flap), and inner thigh (TUG flap).

Q: When can I have breast reconstruction surgery? Can it be done at the same time as my mastectomy?

A: Breast reconstruction can occur immediately after mastectomy or delayed (at a separate time after the mastectomy). Most women undergo immediate breast reconstruction.

Q: How long after chemotherapy or radiation therapy can DIEP flap breast reconstruction be done?

A: Usually about four to six weeks after chemotherapy. Usually about six to twelve months after radiation therapy. You have to wait for the acute effects of radiation to the skin to resolve prior to any breast reconstruction.

Q: Will I have sensation in my reconstructed breast?

A: No, you will not have normal sensation as before.

Compared with an implant, DIEP flap reconstruction provides a more natural look and feel that will mature and change as a woman's body ages, and that won't have to be replaced because of rupture or other problems.

Q: What are the benefits of using my own body's tissue for breast reconstruction compared with having a breast reconstructed with an implant?

A: It is your own body tissue. It will give you a more natural look and feel that will mature and change with you as your body ages. You don't have to worry about replacing it, as may happen with an implant due to implant rupture, infection, or capsular contracture.

Q: What is microsurgery, and why is it used in breast reconstruction?

A: Free tissue transfer is the transfer of tissue taken from one part of the body and moved to another part of the body far away by detaching the blood vessels and reconnecting the blood vessels using microsurgery. Microsurgery is surgery performed with use of a microscope to re-connect tiny blood vessels to re-establish blood flow to the flaps.

Q: If I do not want to use, or can't use, my abdomen for a DIEP flap breast reconstruction, are there other flap options?

A: Latissimus flap (from the back) is a possible option, but what is usually requires an implant, gluteal flap (tissue from the buttocks), and TUG (tranverse upper gracilis) flap using tissue from the inner thigh.

Q: Is there a reason why few surgeons perform perforator DIEP flap breast reconstruction?

A: It involves microsurgery and advanced technical skills to dissect the blood vessels from the rectus muscle.

Q: How long does DIEP flap surgery take to perform?

A: For unilateral DIEP it takes six to eight hours, and for bilateral DIEP ten to twelve hours.

The reason why few breast centers offer DIEP flap breast reconstruction is because the surgery is very complex and the procedure requires very sophisticated, advanced technical skills including microsurgery.

Q: Does the DIEP flap surgery have a higher complication rate than other types of breast reconstruction?

A: DIEP flaps can be associated with more fat necrosis (lump) than muscle-sparing free TRAM flaps.

Q: How long will it take for me to get back to my normal routines and exercise after a DIEP flap breast reconstruction?

A: About four to six weeks.

Q: Is recovery after DIEP flap surgery more painful and difficult than after other types of breast reconstruction?

A: No, it should be less because with DIEP flap surgery the rectus (abdominal) muscle is spared.

Q: What if my breast cancer comes back after I have had a breast reconstruction? Is DIEP flap associated with a higher recurrence rate?

A: No, there are no studies that show breast reconstruction adversely affects detection of breast cancer recurrence, or is associated with a higher recurrence rate.

Q: Will my health insurance plan cover the cost of breast reconstruction with a DIEP flap?

A: Yes, federal and New York mandates state that insurance plans that cover mastectomy must also cover breast reconstruction deemed appropriate by the plastic reconstructive surgeon and the patient.

Q: What distinguishes DIEP flap breast reconstruction surgery done at Stony Brook?

A: We do a high volume of microsurgery, including DIEP flap breast reconstruction, with a dedicated microsurgery team. We also have the state-of-the-art technology and equipment for microsurgery.

Read about breast reconstruction at the Carol M. Baldwin Breast Care Center of Stony Brook Medicine. For more information about our breast reconstruction program, please call 631-444-4666.