Stacked DIEP Flap
Stacked DIEP flap reconstruction is a newer approach to DIEP that can be used to reconstruct one breast in women who don’t have a lot of extra belly tissue and therefore aren’t eligible for standard DIEP surgery.
DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. In a standard DIEP flap reconstruction, fat, skin, and blood vessels are cut from the wall of the lower belly and moved up to your chest to rebuild your breast(s). Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. DIEP is often referred to as a muscle-sparing or muscle-preserving type of flap, which means that no muscle should be removed or cut. Because of this, 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, which do involve cutting the muscle tissue either partially (muscle-sparing TRAM) or completely (conventional TRAM).
Some women don’t have enough belly tissue to be good candidates for DIEP reconstruction. Typically they’ve had to use either an implant or tissue from other sources, such as the hip or thighs, to reconstruct the breasts. If you’re in this group, you would need to do this if you’re having both breasts reconstructed. However, the stacked DIEP flap may be an option for you if only one breast is being reconstructed. In this approach, the plastic surgeon takes the entire flap of tissue from the lower abdomen (one continuous piece), or one flap from each side (two pieces), and uses the tissue to reconstruct the single breast. The surgeon can either “stack” the flaps, or fold the intact flap in half, to create the new breast. Stacking the flaps in this way often can provide the volume that is needed.
Because the stacked DIEP flap procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer it and it's not available at all hospitals. Stacked DIEP reconstruction is even newer than the standard DIEP procedure, so this can add to the difficulty of finding an experienced surgeon. If you're considering a stacked 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 can offer stacked DIEP flap reconstruction.
Because skin, fat, and blood vessels are moved from the belly to the chest, having a stacked DIEP flap means your belly will be flatter and tighter -- as if you had a tummy tuck. Still, a stacked 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.
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. Again, the stacked DIEP flap procedure can only be used for unilateral (one-sided) breast reconstruction. If you’re having both breasts reconstructed, you need to consider other sources for the tissue flaps, such as your buttocks, thighs, or back. Or you can have reconstruction with implants.
A stacked DIEP flap is also not a good choice for:
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. If you have had a C-section, hysterectomy, gall bladder surgery, appendectomy, or tubal ligation, etc., you may still be a candidate for a stacked DIEP flap.
Women whose abdominal blood vessels are small or not in the best location to do a stacked DIEP flap. (A new approach called the APEX FlapCM may be useful in this situation, but availability is very limited.)
Stacked DIEP flap reconstruction: What to expect
During stacked DIEP flap surgery, an incision is made along your bikini line and the surgeon removes one long flap of skin, fat, and blood vessels from the lower half of your belly, or he removes one flap from each side. This tissue is moved up to your chest and formed into a breast shape. No muscle should be moved or cut in a stacked DIEP flap.
The tiny blood vessels in the flap (or flaps), which will feed the tissue of your new breast, are matched to blood vessels in your chest and carefully reattached under a microscope.
Stacked DIEP flap reconstruction surgery takes about 4-6 hours.
After stacked 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 stacked DIEP flap, you usually stay in the hospital for about 3-4 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 weeks to recover from stacked 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), if you’ve had immediate reconstruction you might feel worse than someone having mastectomy alone and it will probably take you longer to recover. You'll have to take care of multiple incisions: on your breast, your lower abdomen, and around your belly button, and you'll probably have drains in your reconstructed breast 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.
Stacked DIEP flap surgery risks
Like all surgery, DIEP flap surgery has some risks. Many of the risks associated with stacked DIEP flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to stacked 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 the tissue isn’t getting enough blood supply, you’ll know it within a few days after surgery, based on the appearance of these symptoms. Otherwise, you know the tissue is getting enough blood supply and long-term problems with tissue breakdown 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, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. 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 stacked DIEP flap, you have a small risk of residual muscle weakness, but the risk of hernia is much lower than with any type of TRAM flap. This is because a DIEP flap uses no muscle to rebuild your breast.
— Last updated on February 9, 2022, 8:32 PM