A DIEP flap is similar to a muscle-sparing free TRAM flap, except that no muscle is used to rebuild the breast. (A muscle-sparing free TRAM flap uses a small amount of muscle.) A DIEP flap is considered a muscle-sparing type of flap. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen.
In a DIEP flap, fat, skin, and blood vessels are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. (In a properly performed DIEP, no muscle is cut or removed; if you’re having DIEP flap, make sure this will be the case.) Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because no muscle is used, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to any of the TRAM flap procedures.
Because the DIEP flap procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer DIEP and it's not available at all hospitals. If you're considering a DIEP flap, you may have to research the surgeons and facilities that offer what you want. Your doctor may be able to refer you to plastic surgeons who specialize in DIEP flap reconstruction. (For more information, see Finding a Qualified Plastic Surgeon.)
Tissue can be taken from your belly for breast reconstruction only once. So if you're thinking about prophylactic removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. If you have DIEP flap reconstruction on one breast and then later need reconstruction on your other breast, tissue for the second, later reconstruction will have to come from your buttocks or back. Or you can have reconstruction with an implant.
Because skin, fat, and blood vessels are moved from the belly to the chest, having a DIEP flap means your belly will be flatter and tighter -- as if you had a tummy tuck. Still, a DIEP flap does leave a long horizontal scar -- from hipbone to hipbone -- about one-third of the way between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, the abdomen is closed. No mesh material is required to support the abdominal wall, as may be the case with a TRAM flap. Your navel is then brought back out through a separate incision and reshaped.
While DIEP flap breast reconstruction is popular because it doesn't move or cut muscle (which usually means a shorter recovery time than a TRAM flap), a DIEP flap isn't for everyone. It's not a good choice for:
Thin women who don't have enough extra belly tissue. However, there is a newer “stacked” approach that can sometimes work for these women.
Women who already have had certain abdominal surgeries, including colostomy (surgery that attaches the large intestine to an opening in the abdominal wall) or abdominoplasty (tummy tuck). This does not include midline incisions extending from the belly button to the pubic region or other routine abdominal operations.
Women whose abdominal blood vessels are small or not in the best location to do a DIEP flap. (A new approach called APEX FlapCM may be useful in this situation, but availability is very limited.)
DIEP flap reconstruction: What to expect
During DIEP flap surgery, an incision is made along your bikini line and a portion of skin, fat, and blood vessels is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape. No muscle should be moved or cut in a DIEP flap.
The tiny blood vessels in the flap, which will feed the tissue of your new breast, are matched to blood vessels in your chest and carefully reattached under a microscope.
DIEP flap reconstruction surgery takes about 6 to 8 hours.
After DIEP flap reconstruction surgery: You'll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you're in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.
You'll then be admitted to a hospital room. For a DIEP flap, you usually stay in the hospital for about 5 days.
Your doctor will give you specific instructions to follow for your recovery. For detailed information on how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect page.
It can take about 6 to 8 weeks to recover from DIEP flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you've had surgery at two sites on your body (your chest and your belly), you might feel worse than someone having mastectomy alone and it will probably take you longer to recover. You'll likely have to take care of multiple incisions: on your breast(s), your lower abdomen, and around your belly button, and you'll probably have drains in your reconstructed breast(s) and in your abdominal donor site. If you had axillary nodes removed during this surgery, you could have yet another incision under your arm(s).
As with any abdominal surgery, you may find that it's difficult or painful to sit down or get up from a sitting position. It also might be hard to get in and out of bed. Your doctor or physical therapist can show you how to move until your abdominal area heals. If you have severe pain, ask your doctor about medications you can take.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after DIEP flap reconstruction.
It sometimes takes as long as a year or more for your tissue to completely heal and for your scars to fade, and you may decide to have additional “finishing” work done, such as reshaping the flap or reconstructing a nipple.
DIEP flap surgery risks
Like all surgery, DIEP flap surgery has some risks. Many of the risks associated with DIEP flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to DIEP flap reconstruction.
Tissue breakdown: In rare instances, the tissue moved from your belly to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.
“If necrosis is going to be a problem, it will happen in the short term -- within the first few days after surgery,” says Frank J. DellaCroce, M.D., FACS, plastic surgeon and co-founder of the Center for Restorative Breast Surgery. “If it doesn’t, then you know the tissue is getting enough blood supply and long-term issues with this are not a concern.”
Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, over time, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis, and the lump is usually not noticeable until the rest of the flap softens and the swelling is gone (6-8 months). These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don't go away on their own, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.
Hernia or muscle weakness at the donor site: A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias occur in the abdomen. They usually develop when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy.
If you have a DIEP flap, you have a small risk of hernia. Your risk of hernia is much lower with a DIEP flap than with any type of TRAM flap. This is because a DIEP flap uses no muscle to rebuild your breast. Still, after any abdominal surgery, there is some risk of hernia.
Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically repairing the opening in the muscle wall. The surgery is generally done on an outpatient basis.
APEX flapCM: A new approach to DIEP reconstruction
One of the biggest concerns with flap reconstruction is making sure that the tissue has a strong blood supply after it is moved to the chest area. Sometimes, the blood vessels in a DIEP flap are not located in a single line in the rectus abdominis muscle (the lower abdomen). As a result, the surgeon may have to decide between cutting muscle between the vessels to bring them together or leaving the flap with less blood flow. If muscle is cut through to improve the blood flow in the flap, the DIEP flap is no longer a completely “muscle-sparing/muscle-preserving” surgery, and recovery can be more difficult. Ideally, all muscle should remain intact to preserve the strength of the abdominal wall and minimize any long-term impact on your ability to do your normal activities.
Surgeons at the Center for Restorative Breast Surgery in New Orleans have pioneered a new approach, called the APEX FlapCM, (Abdominal Perforator Engineered vascular eXchange Flap), which minimizes impact on the lower abdominal muscle. The APEX FlapCM also allows for an unlimited increase in blood flow to the new flap. In this new approach, if there is a risk for destroying muscle in order to achieve blood flow, the surgeons visually examine the patient’s natural blood vessel anatomy and re-engineer its design. This allows surgeons to create a soft, living breast while simultaneously preserving the abdominal muscle in its original condition. The blood vessels are rearranged within the flap itself to add proper blood flow. This helps to ensure that the tissue is well-nourished, maintains its volume, and remains soft and healthy after it is moved. This also helps reduce the risk of partial flap failure (tissue breakdown due to inadequate blood supply) and fat necrosis (fat tissue turning into scar tissue, also due to poor blood supply). At the same time, the surgeon can avoid damage to the muscle that lies around and between the blood vessels that feed the flap.
Although this DIEP technique isn’t widely available, it may become more available in the near future. In the meantime, if you are having a DIEP flap reconstruction, you can ask your surgeon about any possibility that he or she would need to cut into the lower abdominal muscle. Again, it’s best if your surgeon can avoid cutting the muscle while also making sure there are enough blood vessels to feed the flap after it is moved and formed into your new breast.
— Last updated on February 9, 2022, 8:32 PM