A DIEP flap involves taking the excess skin and fat from the lower abdomen and using it to reconstruct a new breast following (delayed) or at the time of (immediate) mastectomy. The skin and fat with its blood vessels are carefully detached from your abdomen before being reconnected to a new blood supply in your chest. It is called DIEP because the blood vessels taken from the abdomen are called the deep inferior epigastric perforator blood vessels. It is a complex operation that takes about 5 - 7 hours. DIEP flaps give warm, soft and pliable reconstructed breasts that resemble natural breast tissue, and are therefore considered the gold standard for breast reconstructive procedures. In addition, the removal of tissue from your abdomen results in a flatter tummy, as if you have had a tummy tuck (abdominoplasty).
Nearly all breast reconstructions require two or more operations. When using the DIEP flap, whilst as much of the reconstruction is done at the time of the main flap transfer operation, there is often a need for a second very small operation to refine and adjust the reconstruction, as well as undertake a nipple reconstruction. Despite the need for more than one operation, the result should be life-long and the reconstruction should age with you naturally. It should also change with your body weight in a similar way to your breast. This is one of the major differences between flaps and implants, as implant-based reconstructions frequently need revision surgery as the years go by.
Scars
There will be scars on the lower abdomen and around the belly button similar to a tummy tuck scar. We aim to place these as low as possible so they can be hidden by underwear. Scar healing can be unpredictable and although most scars achieve a satisfactory appearance by 18 months some can be red, raised, stretched and uneven. Some can require revision in the second operation.
Tummy strength
No abdominal muscle is removed in a DIEP flap operation and abdominal strength is maintained long term. Weakness of the abdominal wall after a DIEP flap procedure may result in a bulge but this is rare. Post-operative abdominal exercises can sometimes improve this over time. Very rarely, damage to the muscle may produce a hernia that will require additional surgery for correction. This is an extremely rare complication because the abdominal muscle is left intact, which is the great advantage of the DIEP technique compared to the previously used TRAM flap breast reconstructions.
Microsurgery
The blood vessels that supply the piece of tissue being removed from the abdomen have to be carefully dissected and rejoined to blood vessels in the chest wall so that good blood flow is re-established. Any sustained disruption to this flow in the first few days can cause the failure of the reconstruction. This is very rare (less than 0.4%) and to ensure that this does not happen regular observations are maintained during your in-patient stay. If there are any concerns about the blood flow you may need to go back to the operating theatre to have the join checked. About 1 in 100 women who have a DIEP flap may need one of these 'second checks' in the week after their surgery.
Bleeding
Bleeding can occur with any type of surgery and is not specifically common to DIEP flap procedures. You will have 1-2 drains in your reconstructed breast and 2 drains in your tummy to help prevent any blood clots collecting. These will be removed before you go home.
Infection
The development of a serious infection is rare. Antibiotics are given at the time of the surgery to reduce the chances of this happening. Most infections resulting from surgery appear within a few days of the operation and require a further course of antibiotics.
Seroma
A build-up of fluid under the wound site (seroma) happens in 10% of women after the abdominal or breast drains have been removed, and usually gets better within a few weeks. The fluid can be drained at an outpatient appointment.
Sensation
The breast reconstruction flap will have little or no light-touch sensation. Over 12 to 18 months, the periphery of the reconstruction does regain some sensation and most patients can feel movement of the breast on the chest wall.
Fat necrosis
Just as skin can form a scar so can the underlying fatty tissue when it is healing in the new breast. This type of scarring is known as fat necrosis and is not serious. Usually they improve spontaneously with massage.
Symmetry
Most women's breasts are asymmetrical (not perfectly equal in either size or shape). With advancing age, the breast also tends to ptose or droop. Although every effort is made to create a new breast to match the opposite healthy one, it is rarely possible to achieve perfect symmetry. After discussion with us and depending on your wishes/needs it may be deemed appropriate to perform a mastopexy (hitching up) or reduction operation on the other breast in order to match the breasts.
Before Surgery
Before your procedure we will arrange for a CT angiogram to look at the blood vessels in your anterior abdominal wall. This is a 15 minute scan that helps in the planning of the procedure and reduces the operating time.
You will also have a pre-operative assessment with one of our team who will go through some health check questions and examine you to make sure you are fit for surgery. They will also take blood tests.
If you smoke you should stop at least six weeks before surgery to reduce the likelihood of post-operative complications. If you are unwell before the operation, please call DRG Plastic Surgery on 020 8393 5160 as the date of surgery may need to be postponed. No aspirin or medication containing aspirin should be taken for ten days before surgery.
It is useful if you could bring a non-wired comfortable and supportive bra, like a sports-bra, that you do not mind being cut. After the operation, a hole is often made in the bra so that the DIEP flap can be examined without having to remove the bra frequently.
After Surgery
The procedure takes around 5-7 hours. We will be more than happy to call one of your relatives afterwards to update them on your progress. Visiting times will vary according to which hospital you have your procedure in.
When you wake up you will be in the high dependency unit to enable close monitoring of the breast reconstruction. It is usual to feel drowsy and a little disorientated for some time post- operatively. If you have pain or feel sick, you should tell the nursing staff so that they can give you the appropriate medication. The breast(s) will feel a little sore after surgery particularly when the arms are moved, but this rapidly improves over the first few days. It is likely that your hips and knees will be bent, perhaps on cushions or with the bed bent in the middle, to take the strain off the abdominal wound.
You will be given pain relieving medication and the anaesthetist will discuss this with you before the procedure. A warming blanket is also usually in place for the first night to stop you getting cold, and some intermittent compression devices on the calves to keep the blood circulating in the legs and again reduce the chances of deep vein thrombosis. After the first night, you are then usually transferred to the ward for standard nursing care. On the first day following surgery, you will need help to sit out in a chair for a short time. You can usually get out of bed by yourself 2 days after the operation. You can normally take a shower on day 2 or 3.
On the day of discharge, you will be given a clinic appointment for approximately 7 days' time. At that appointment, the dressings will be removed by a nurse and the wound checked. We will see you again around day 14 or earlier if there are any concerns. You should continue to shower daily but it is not advisable to soak in the bath for at least 3 weeks.
After 2-4 weeks you may go back to non-physical activity and resume driving a car, but check this with your insurance company as some do vary in their recommendations. Four weeks after your operation you may resume gentle exercise, but violent movements, upward stretching of the arms and high intensity cardio vascular exercise are not advisable for 6-8 weeks.
There are many factors that can affect your individual operation, your recovery and the long-term result. These include your overall health, your chest and body shape, previous breast surgery, radiotherapy, any bleeding tendencies that you have and your ability to heal. Smoking and certain medications can also have effects on the post-operative recovery period. Issues specific to you need to be discussed with Miss Rose and are not covered here. Please make sure you ask any further questions before you sign the consent form.