MUSC Advanced Breast Reconstruction program

DIEP Flap (Abdomen)

While it is a complex process that requires advanced microsurgery, use of the DIEP flap has emerged as one of the most effective and desirable options for breast reconstruction.

The name of the flap comes from the main blood vessel that runs through it – the deep inferior epigastric perforator – which is located in the lower abdomen. During the procedure, an incision is made from hip to hip near the bikini line to access the blood vessels that keep the skin and fat alive. The flap is then disconnected from the abdomen and positioned on the chest.

In contrast to the TRAM procedure, which also draws tissue from a woman’s abdomen, no muscle is relocated with the DIEP procedure. By sparing the abdominal muscles, patients experience less pain after surgery, enjoy a faster recovery, maintain their abdominal strength long-term and have fewer abdominal complications, such as hernia. No muscle or motor nerves are damaged when the DIEP flap is removed.

As with the TRAM procedure, women who undergo DIEP reconstruction are able to enjoy a flatter abdomen with results that mimic a “tummy tuck.”

Stages of DIEP Reconstruction


Stage 1: Main Procedure
The purpose of this first procedure is to remove the tissue flap from the abdomen, position it on the chest and keep it “alive.” During this stage, the plastic surgeon will remove the perforator flap from the abdomen, attach the tissue at the mastectomy site, striving to keep the tissue “alive.”

If reconstruction is going to be done at the time of mastectomy, the breast surgeon will leave a pocket where the plastic surgery team can position the transferred tissue. If time has lapsed since your mastectomy, a plastic surgeon will make an incision through your previous scars to create a space for the flap.

Once the flap has been harvested, the plastic surgeons go under the microscope and connect the vessels in the flap to the vessels in the chest wall and under the arm. While the transfer is complex, our plastic surgeons have performed this type of microsurgery hundreds of times, and they operate in pairs so you will spend less time under anesthesia. Reconstruction of one breast (unilateral) generally take three to four hours at MUSC, while reconstructing two breasts (bilateral) takes six to seven hours.

Afterward, you will remain in the hospital three to four days, first in ICU and then a step-down setting. This is not because you are sick – you will be up and walking the day after surgery – but to ensure that you have a nurse dedicated to monitoring the success of the transferred flap. Our success rate with DIEP and other free flaps is 97-98 percent.

Your surgeon often can fix minor problems that threaten a flap’s success while you are recovering in the hospital. Once you are discharged, you can expect your flap to live with you for the rest of your life, though the reconstruction is not complete.

Stage 2: Tweaking stage
This stage is more cosmetic in nature and can be done as soon as three months after your first surgery. The outpatient procedure usually takes an hour and allows the surgeon to address issues with breast and abdominal issues.

If you underwent a unilateral reconstruction, your other breast can be lifted, reduced, augmented or enhanced with fat grafting to create symmetry between the two breasts. If both breasts were reconstructed, your surgeon might do some further shifting or shaping so the breasts match as much as possible. In addition, the surgeon can address scarring or “dog ears” – pointy ends of skin on the side of each hip where the flaps were removed.

Depending on the amount of tweaking that is necessary, nipple reconstruction may be able to be completed in this stage.

Stage 3: Nipple Reconstruction/Tattoo
If it is not done during Stage 2, nipple reconstruction can be completed at this time using local anesthetic in a clinic setting. As early as six weeks after nipple reconstruction, you will return to the clinic for the finishing touch – areola tattooing by our specially trained 3-D artist.  The procedures can be scheduled at your convenience and do not have to be done immediately.

DIEP Free Flap Reconstruction

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