DIEP Flap Breast Reconstruction
What is DIEP Flap Breast Reconstruction?
DIEP flap breast reconstruction is an advanced microsurgical procedure that rebuilds the breast using your own tissue from the lower abdomen. DIEP stands for Deep Inferior Epigastric Perforator, referring to the blood vessels that supply the abdominal tissue used in the reconstruction.
Unlike implant-based reconstruction, DIEP flap surgery uses your own skin, fat, and blood vessels to create a new breast mound, without sacrificing your abdominal muscle. The tissue is carefully disconnected from the abdomen, along with its blood supply, and transferred to the chest where it's shaped into a breast and the blood vessels are reconnected using microsurgery.
For women who have undergone mastectomy for breast cancer or as a preventive measure, breast reconstruction can be an important part of physical and emotional recovery. DIEP flap reconstruction offers the advantage of using natural tissue that ages with your body, feels soft and warm, and doesn't require implant replacement over time.
Dr Roger Haddad's expertise in microsurgical techniques makes him well-suited to perform this complex procedure. He has specific training in this operation from his fellowship is Stuttgart, Germany, and has also trained with early pioneers of the operation in Sydney.
ABOUT THE PROCEDURE
Pre-Surgical Planning
DIEP flap reconstruction requires thorough planning and assessment. During your consultation, Dr Haddad will:
Discuss your breast cancer treatment and reconstruction goals
Assess whether you have sufficient abdominal tissue for the reconstruction
Examine your abdomen for scars that might affect blood supply to the tissue
Review your general health, smoking status, and any conditions that might affect healing
Arrange imaging studies (CT angiography) to map the blood vessels in your abdomen
Explain the surgical process, expected outcomes, and recovery timeline
Discuss timing - whether reconstruction will be immediate (at the time of mastectomy) or delayed (after completing cancer treatment)
Not everyone is a suitable candidate for DIEP flap reconstruction. Women who are very thin may not have sufficient abdominal tissue, while certain medical conditions or previous abdominal surgeries may make the procedure inadvisable.
Surgical Technique
DIEP flap reconstruction is one of the more complex reconstructive procedures and typically takes 6-10 hours to complete. It's performed under general anaesthetic at St Vincent's Private Hospital in Darlinghurst.
The procedure involves:
Tissue harvest: A section of skin and fat is carefully removed from the lower abdomen, along with the blood vessels that supply it. Unlike older techniques (TRAM flap), the abdominal muscles are usually preserved, which reduces post-operative pain and helps maintain abdominal wall strength.
Microsurgical transfer: The tissue is moved to the chest and shaped to create a breast mound. Using an operating microscope, Dr Haddad carefully reconnects the blood vessels from the flap to blood vessels in the chest (typically the internal mammary vessels). These connections are typically 1-3mm in diameter and require extremely precise suturing.
Shaping: Once blood flow is established, the tissue is sculpted and positioned to create breast shape and projection. The abdominal incision is closed, resulting in a scar similar to that of an abdominoplasty (tummy tuck).
Nipple reconstruction: If desired, nipple and areola reconstruction is typically performed as a separate procedure several months later, once the breast has settled and any adjustments have been made.
For bilateral reconstruction (both breasts), the surgery takes longer, but tissue from the abdomen can often be divided to reconstruct both breasts in a single operation.
Who is DIEP Flap Reconstruction For?
Ideal Candidates
DIEP flap breast reconstruction may be suitable for women who:
Have undergone or will undergo mastectomy for breast cancer or risk reduction
Have sufficient abdominal tissue (fat and skin) to create a breast mound
Prefer reconstruction using their own tissue rather than implants
Want a reconstruction that feels natural and changes with body weight
Are in good general health and able to tolerate lengthy surgery
Are non-smokers or willing to quit well before surgery (smoking severely compromises flap survival)
Have realistic expectations about surgical outcomes and the recovery process
Are committed to the recovery period this surgery requires
DIEP flap reconstruction can be performed immediately at the time of mastectomy or as a delayed procedure months or years after mastectomy. Each approach has advantages that should be discussed with Dr Haddad.
Who May Not Be Suitable
DIEP flap reconstruction may not be appropriate for women who:
Are very thin with insufficient abdominal tissue
Smoke or are unwilling to stop smoking (this significantly increases the risk of flap failure)
Have significant scarring on the abdomen from previous surgeries that may have damaged blood vessels
Have medical conditions that increase surgical risk or impair healing (such as uncontrolled diabetes or clotting disorders)
Have had previous abdominal surgery that disrupted the blood supply to the lower abdomen
Are unwilling or unable to commit to the lengthy surgery and recovery period
Require post-mastectomy radiation therapy (though DIEP can still be considered, timing and approach require careful discussion)
A thorough evaluation with Dr Haddad will determine whether DIEP flap reconstruction is suitable for your individual circumstances.
Your Recovery & Aftercare
DIEP flap reconstruction involves recovery at both the chest and abdominal sites.
Hospital phase (7 days): You'll spend the first few days in hospital with close monitoring of the flap's blood supply. Pain is managed with medication, and you'll be encouraged to move carefully and begin walking short distances within the first day or two. You will have a catheter in the bladder for a couple of days. An abdominal binder provides support for the abdomen and helps reduce swelling. Most patients have drains in place which are removed when output decreases sufficiently.
First 2-4 weeks: Recovery during this phase focuses on mobilization while avoiding strain on the abdomen. You'll need to avoid bending, lifting, or twisting movements. Most women take 4-6 weeks off work, though this depends on the physical demands of your job..
Weeks 4-8: Activity gradually increases, but you'll still need to avoid strenuous exercise, heavy lifting, and movements that strain the abdominal muscles. The reconstructed breast and abdomen continue to heal and soften during this time.
Months 2-6: Most normal activities can resume, though high-impact exercise should be discussed with Dr Haddad. The breast and abdomen continue to settle. Some numbness in the abdomen and reconstructed breast is normal and may be permanent, though some sensation may return over time.
Long-term: The reconstructed breast will change with your body weight and age naturally, unlike implants. If you gain or lose significant weight, both your natural breast (if you had unilateral reconstruction) and reconstructed breast will be affected. Additional procedures such as nipple reconstruction, symmetry adjustments, or fat grafting may be performed once initial healing is complete.
Dr Haddad will provide specific guidance tailored to your recovery progress.
Surgical Complications & Risks
DIEP flap reconstruction is complex surgery with specific risks that differ from simpler reconstructive options. Understanding these helps you make an informed decision.
General Surgical Risks
Bleeding or haematoma
Infection
Adverse reactions to anaesthesia
Deep vein thrombosis or pulmonary embolism (preventive measures are taken, but the lengthy surgery increases risk)
Risks specific to DIEP Flap Breast Reconstruction
Flap failure: The most serious complication is partial or complete loss of the transferred tissue if blood supply is compromised. This occurs in approximately 1-5% of cases and may require emergency return to surgery or, rarely, complete flap loss requiring alternative reconstruction. Close monitoring in the first 48-72 hours is critical for detecting and addressing any vascular problems.
Fat necrosis: Areas of transferred fat may not survive, forming firm lumps within the reconstructed breast. Small areas usually resolve on their own; larger areas may require removal.
Abdominal complications: Including wound healing problems, seroma (fluid collection), weakness, or bulging of the abdominal wall. While the muscle is preserved in DIEP flap, the abdominal wall may still feel different than before surgery.
Asymmetry: Achieving symmetry between a reconstructed breast and natural breast (in unilateral reconstruction) is challenging. The shape, size, and position may differ, and revision surgery is sometimes requested to improve symmetry. Sometimes an adjustment such as a lift or reduction is required on the normal breast.
Sensation changes: The reconstructed breast will have reduced or absent sensation. The abdomen will also experience numbness in the area where tissue was removed, which may be permanent.
Scarring: Both the chest and abdomen will have permanent scars. The abdominal scar extends across the lower abdomen, similar to a tummy tuck scar. Scar quality varies between individuals.
Hernia: Though the abdominal muscle is preserved, there is a small risk of hernia formation at the donor site.
Delayed wound healing
Microsurgical complications: Problems with the vascular connections may become apparent hours or days after surgery, potentially requiring return to theatre for revision.
The overall complication rate is higher than simpler procedures, though Dr Haddad's microsurgical training and experience work to minimize these risks.
Frequently Asked Questions
How does DIEP flap reconstruction differ from other types of reconstruction?
DIEP flap uses your own abdominal tissue without sacrificing muscle, unlike TRAM flap which takes abdominal muscle. Compared to implant reconstruction, DIEP creates a breast from living tissue that feels warm, soft, and changes naturally with your body over time. It can droop like a natural breast. It doesn't require replacement like implants do, but involves more complex initial surgery and potentially longer recovery.
Will my reconstructed breast look and feel like my natural breast?
The reconstructed breast will usually feel soft and warm like natural breast tissue, and will age and change with weight fluctuations like your body does. However, it will differ from your natural breast in several ways: it will have reduced or absent sensation, won't have a natural nipple initially (this can be created later), and the shape and position may not exactly match a remaining natural breast. The goal is to create a breast mound that restores body contour and symmetry in clothing.
What will happen to my abdomen?
The abdominal incision is similar to a tummy tuck scar - a long scar across the lower abdomen that can typically be hidden beneath underwear. You'll have a flatter, tighter abdomen after the excess skin and fat are removed. However, you'll experience numbness in the lower abdomen, and abdominal strength and function may feel different than before surgery, even though the muscle is preserved.
Can I have DIEP flap if I've had previous abdominal surgery?
It depends on the type and location of previous surgery. Caesarean sections usually don't preclude DIEP flap, but midline scars or extensive abdominal surgery may have disrupted the blood vessels needed for the procedure. CT angiography helps determine whether your blood vessel anatomy is suitable.
How long does the reconstructed breast last?
The reconstructed breast is permanent and made from living tissue. Unlike implants which may need replacement after 10-15 years, DIEP flap reconstruction doesn't require replacement. However, you may choose revision surgery later to adjust shape, improve symmetry, or perform nipple reconstruction. It has been Dr Haddad’s experience that a DIEP flap looks more natural with time, compared to an implant reconstruction which can look less favourable as time passes.
Will I need revision surgery?
Many women have additional procedures after DIEP flap reconstruction. These might include: fat grafting to refine contour, surgery to the opposite breast to improve symmetry, nipple and areola reconstruction, or scar revision. These are typically performed around 6 months after the initial reconstruction, once healing is complete and the breast has settled.
What if I need radiation therapy?
Radiation therapy can affect reconstructed tissue, potentially causing firmness, shrinkage, or contour changes. If radiation is planned after mastectomy, timing and approach to reconstruction require careful discussion. Some women proceed with immediate DIEP reconstruction, while others may choose delayed reconstruction after radiation is complete. Dr Haddad will work with your oncology team to determine the best approach.
When can I return to exercise?
Walking is encouraged soon after surgery. More vigorous activity should wait 6-8 weeks, and high-impact exercise or core-strengthening workouts typically wait 12 weeks or longer. Your abdominal recovery influences when you can safely return to activities that engage core muscles. Dr Haddad will guide you based on your healing progress.
What happens if the flap fails?
If the blood supply to the flap is compromised, you may need to return for urgent surgery to try to salvage it. If the flap cannot be saved, it would be removed and alternative reconstruction (typically with implants or tissue from another donor site) would be discussed once you've recovered. Fortunately, complete flap failure is uncommon in experienced hands.
Can I have DIEP flap for both breasts?
Yes, bilateral DIEP flap reconstruction is possible and the abdominal tissue can often be divided to reconstruct both breasts. The surgery takes longer and recovery may be more demanding, but it's regularly performed for women having bilateral mastectomies.
NEXT STEPS
Request a Consultation
DIEP flap breast reconstruction is a significant undertaking that offers the benefit of reconstruction using your own tissue. If you're considering reconstruction after mastectomy, Dr Haddad can help you understand whether this approach is suitable for you and what you can expect from the process.
During your consultation, Dr Haddad will assess your individual circumstances, explain the procedure in detail, discuss alternatives, and answer your questions. He works closely with breast surgeons and oncology teams to ensure reconstruction is appropriately timed within your overall treatment plan. Understanding the surgery, recovery, and realistic outcomes will help you make the decision that's right for you.