DIEP FLAP FAQ’s
The DIEP flap (Deep Inferior Epigastric artery Perforator) is a method of breast reconstruction using your own tissue. Excess skin and fat from your lower abdomen is used to reconstruct one or both breasts, without disturbing the adjacent muscle. This method of breast reconstruction leads to a natural appearing result, while minimizing discomfort and avoiding the long-term risks associated with implants. Drs. Bailey and Morton specialize in DIEP flap reconstruction.
Yes. If you are a patient who is planning breast reconstruction with implants but have not been told about the option of using your own tissue (or the DIEP flap), please contact our office at any time during the reconstructive process. This may be before mastectomy, after tissue expander placement, or even years after completing implant based breast reconstruction. You may not have heard about this option as most plastic surgeons do not perform the DIEP flap procedure.
There are also many patients who are turned down or told they are not candidates for a DIEP flap. If this is you, please contact our office. We are happy to provide a second opinion at any time during your journey (including after completing your reconstruction). You can be reassured that this is a very common reason for consultation – a significant portion of our practice focuses on patients who are dissatisfied with their implant reconstruction and want to consider a DIEP flap.
Some women are turned down for the DIEP flap because they do not have enough abdominal tissue (for example, ‘You’re too skinny for a DIEP flap.’). These patients may be candidates for a stacked or bi-pedicled DIEP flaps. A stacked flap (or bi-pedicled flap) is a technique used to maximize the abdominal tissue that you have available to reconstruct one breast. The stacked or bi-pedicled flap is performed to allow a patient to achieve their desired breast size without having to use implants. Drs. Bailey and Morton perform both stacked and bi-pedicled flaps.
To be a candidate for a DIEP flap you must have unwanted lower belly tissue and the need to reconstruct part or all of your breast. This may include patients who have tuberous breast(s), congenital absence of a breast/Poland syndrome and those who have undergone lumpectomy or mastectomy (this includes patients who are dissatisfied with their breasts after lumpectomy). Reasons you cannot have a DIEP flap include having had a tummy tuck in the past or medical problems including severe heart disease including heart failure, untreated coronary artery disease or severe exercise intolerance (cannot climb one flight of stairs).
Those patients not candidates for a DIEP flap may be candidates for the PAP flap, an upper inner thigh version of the DIEP flap.
No. The DIEP flap can be used for many reasons. Drs. Bailey and Morton routinely perform DIEP flaps for patients after lumpectomy with or without radiation and also in patients who are dissatisfied after implant reconstruction. They also perform DIEP flaps for patients with congenital conditions such as absence of a breast or severe breast asymmetry.
If you have yet to undergo mastectomy, we most commonly recommend placing a tissue expander at the time of your mastectomy, and, less frequently, going “flat” for a short period of time if you are to receive radiation. Placing a tissue expander prior to a DIEP flap is referred to as “delayed-immediate” reconstruction and is the preferred approach for several reasons. If a DIEP flap is performed at the same time as your mastectomy, this combines two very large operations and increases your risk of complications. This includes placing you at higher risk for returning to the operating room emergently and the potential that the DIEP flap fails.
Rather than immediately reconstructing your breast at the time of mastectomy (which seems like a great idea!), we recommend placing a tissue expander. This allows you to make an informed decision regarding your method of reconstruction (implant vs. own tissue/DIEP flap), and minimizes complications. Drs. Hutter, Bailey and Morton then allow you to recover from your mastectomy and schedule your DIEP flap 1-3 months later. This timeline is flexible and some patients choose to wait a year or more with their tissue expander in place so that they may schedule their DIEP flap when most convenient from them and for their family. If you are to receive radiation after your mastectomy, it may be beneficial to not place a tissue expander. Please discuss this with Drs. Bailey, Hutter or Morton.
The DIEP flap is a tissue transplant within your own body. Drs. Bailey and Morton move skin and fat from where you don’t want it (your lower abdomen) to where you do want it (your mastectomy site). When they remove unwanted excess skin and fat from your lower abdomen, they leave the muscle behind, a crucial part to minimizing weakness in your abdomen after surgery. They then transplant this tissue to reconstruct your breast and connect blood vessels of the DIEP flap to the blood vessels of your breast. This allows the transplanted tissue to survive and to function as your own natural tissue reconstruction. Drs. Bailey and Morton specialize in this procedure.
You will remain in the hospital between 2-3 days following a DIEP flap. You will continue to recover at home over the next 4-8 weeks to regain energy, strength, and comfort with your newly reconstructed breast or breasts and tight abdomen. From a historical perspective, just 5 years ago this procedure resulted in a 5-7 day stay in the hospital. We have evolved significantly since that time. The time required to recover from a DIEP flap is the same, or sometimes less, than recovering from implant based reconstruction.
Drs. Bailey and Morton pride themselves on utilizing the most advanced techniques, including for your pain control. They advocate on behalf of their patients to use EXPAREL®, which is a long acting numbing medication that dramatically decreases postoperative pain. They also use state of the art Enhanced Recovery After Surgery (ERAS) protocols to make your recovery as safe, quick and comfortable as possible.
Yes! The majority of patients undergo an additional revision (“touch up”) procedure 3 months after DIEP flap reconstruction. This is an outpatient surgery, where you are discharged home the same day and performed in Dr. Bailey and Morton’s cosmetic surgery center. If only one breast was reconstructed, this procedure will generally include a lift or augmentation of your native breast (depending on your desires). You typically also undergo breast and body sculpting via liposuction and fat grafting. If both breasts were reconstructed, revision procedures typically involve fat grafting and shaping of the reconstructed breast in addition to the body sculpting and abdominal contour adjustments. These “touch-up” procedures are considered the last phase of your reconstruction and are always covered by insurance.
Yes. Drs. Bailey and Morton can perform a simultaneous DIEP reconstruction and DIEP augmentation if you are planning to undergo a single mastectomy and would like your native/remaining breast to be larger. If you do not have cancer and wish to consider augmentation using DIEP flaps, we also perform this operation
When patients are candidates for both implant-based construction and the DIEP flap, they are significantly happier with DIEP flap reconstruction. Patients feel more satisfied with the appearance of their breast(s) and abdomen, feel that their health and quality of life are enhanced, and have other more subtle areas of improvement (less shoulder range of motion decrease, weakness and pain) after a DIEP flap. All of these reasons lead to happier long term results after DIEP flap reconstruction when compared with implant reconstruction.
Drs. Bailey and Morton currently offer the DIEP flap at two sites: The University of Washington Valley Medical Center and Overlake Medical Center. They prefer both hospitals because of their state-of-the-art practices. In addition, despite being large hospitals, but institutions offer a “community hospital” atmosphere. You can have your operation performed at either hospital, depending on your preference.
Alternative flap procedures are part of Dr. Morton and Bailey’s expertise. The PAP flap (Profunda Artery Perforator or ‘inner thigh flap’) is a great option for patients who are hoping to avoid implants but are not candidates for the DIEP flap because they do not have enough tissue or had surgeries in the past do not allow them to have a DIEP flap.
Many times the answer is ‘Yes,’ but Drs. Bailey and Morton will get a specialized scan (CT scan) of your abdomen to make sure you are a candidate prior to surgery.
Online decision aids to be extremely helpful for our patients. This allows you to listen to patient testimonials, read and view pictures of individual breast reconstruction outcomes. These testimonials are from patients across the globe, not just those from our practice. We have found https://breconda.bcna.org.au/ to be most helpful, and recommend visiting this site at least once prior to making a final decision regarding your breast reconstruction.
Implant Reconstruction FAQ’s
Most women are candidates for 2-stage tissue expander to implant reconstruction, and, less often, direct to implant reconstruction. Implants are the most common form of breast reconstruction in the world. Those patients typically favoring implants over the DIEP or PAP flap include those with very little abdominal tissue, those who would like to minimize the amount of scars they have (especially on their abdomen), or those women who have not completed child-bearing. Though they are performed by a greater number of plastic surgeons compared to the DIEP flap, they are not necessarily the best option for every patient.
Many patients may be candidates for consideration of direct-to-implant reconstruction. This is a very appealing option to patients, but we have learned that this rarely results in the “one and done” operation patients are desiring. Most patients who undergo direct-to-implant reconstruction will undergo at least one revision operation in the future.
This ultimately depends on your goals. Women who undergo radiation (before or after implant placement) face higher complication rates (including loss of reconstruction) and are less happy with their result, especially when compared to those who received a DIEP flap. This has to do with many issues, but, simply, the breast is much harder to reconstruct with implants when it has been irradiated. There is also significantly more risk when attempting to do so. Many times, supplementation with non-radiated tissue (either a latissimus dorsi flap from your back, or considering complete reconstruction with the DIEP flap with or without implants) leads to an improved and more natural appearance of the reconstructed breast.
While implants are some of the most scrutinized medical devices on the market, they are safe and widely used in breast reconstruction and augmentation. As long as you understand the risks of implants and are a candidate for their use, they can be utilized for your breast reconstruction. The best way to determine whether implants are appropriate for you is through a thorough discussion of your goals and desires with Drs. Bailey, Hutter or Morton.
Of note, The FDA has placed a “black box warning” on breast implants (updated September 2020), requiring that patients be informed of their potential risks prior to implantation. These warnings include:
- Breast implants are not considered lifetime devices;
- The chances of complications increases over time;
- Some complications require more surgery;
- Breast implants have been associated with the development of a cancer of the immune system called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL);
- BIA-ALCL occurs more commonly in patients with textured breast implants than smooth implants, and deaths have occurred from BIA-ALCL;
- Breast implants have been associated with systemic symptoms.
Drs. Hutter, Bailey and Morton generally do not recommend the use of textured devices because of the reported risk of BIA-ALCL. This includes your tissue expander, should you require one. Please discuss this further with them at your consultation.
Some postoperative complications including infections can be more serious when you have an implant in place. When there is concern that your implant is infected, Drs. Bailey, Morton and Hutter typically recommend returning urgently to the operating room to wash out the implant pocket with antibiotics. You will also likely be admitted to the hospital for intravenous antibiotics. While implant infections are difficult to treat with the prosthesis in place, every effort is made to save your implant. Of note, an infection following a DIEP flap is typically not as serious as with an implant, as there is no foreign body in place.
Silicone and saline implants are both available for use in breast reconstruction. Both are constructed with a silicone shell, so there is no truly “silicone free” implant. In general, Drs. Hutter, Bailey and Morton recommend smooth (not textured) silicone implants for breast reconstruction. Silicone implants are more natural in feel and appearance and have less risk of rippling (causing visible ripples in your breast).
Drs. Morton, Bailey and Hutter typically take a “prepectoral approach”, which is defined as placing tissue expanders and implants above the muscle. This minimizes postoperative pain, reduces the mobility of your implant after surgery and ultimately results in a more natural appearance.
Many times we use cadaver skin/acellular dermal matrix to improve the shape and overall aesthetics of your reconstructed breast. Drs. Hutter, Morton and Bailey make a decision in the operating room as to whether or not you would benefit from this product. They use acellular dermal matrix more often when you may receive radiation after surgery, or when you are undergoing direct to implant reconstruction. When a tissue expander is placed in preparation for a DIEP flap, acellular dermal matrix is almost never used as it offers little benefit in this scenario.
Capsular contracture occurs when your body, over a period of years, forms a tight scar around your breast implant. This results in a very unnatural appearing “stuck on” reconstructed breast. This is a very difficult problem to fix, and almost always requires an additional operation (which is why we want you to know implants are not lifetime devices and may require further surgery years after completing your reconstruction). When capsular contracture recurs after surgical repair, we generally recommend having the implant removed and “going flat” for a period of 6-12 months prior to considering further reconstruction. The only way to avoid the risk of capsular contracture is to not have implants.
This is a common misconception. The amount of time consumed by implant based reconstruction is typically longer than that of DIEP flap reconstruction. Breast reconstruction is a 1 year process from time of diagnosis to completion of reconstruction, and more time is required to perform implant reconstruction due to the increased number of revision procedures required to “fine tune” or “touch up” implants and the recovery period involved with each of these operations. Please see the table below outlining the typical recovery timeline for each method of breast reconstruction for more information.
Yes. Many women are dissatisfied with their reconstruction, which is typically no fault of their reconstructive surgeon. Many times this is the result of the lack of longevity of implant based breast reconstruction. There are also times patients are dissatisfied after DIEP flap reconstruction, frequently due to the natural changes that occur with aging. If this has occurred for you, we always strongly encourage you to first have a discussion with your original reconstructive surgeon. If after this you would like a second opinion, or if that surgeon is no longer available, we are always happy to provide this.
Yes. We frequently help patients who no longer want implants to achieve their desired result. Often these patients are dissatisfied with their implants and/or would like to be considered for a DIEP flap for the additional benefits it affords.
Any concern related to your breast reconstruction will be addressed with candor and skill by our surgeons. If anything is bothering you, we will give you our honest assessment and recommendation.
Following lumpectomy, patients may feel that their breasts are asymmetric or lopsided. Drs. Bailey, Morton and Hutter have multiple tools to address the appearance of your breasts. Sometimes an outpatient procedure may be adequate to resolve your issue. Sometimes, our team will recommend consideration of DIEP flap reconstruction.
There are unique scenarios where the combination of a DIEP flap and implants are a patient’s best option. This typically involves a primary procedure to remove the breast and place a tissue expander, followed by DIEP flap reconstruction, and a revision procedure where an implant is placed. Ultimately, this depends on your goals and desires, and should be discussed with Drs. Bailey, Morton or Hutter.
The Profunda Artery Perforator (PAP flap/inner thigh flap) is a wonderful option for patients in this situation. Drs. Bailey and Morton specialize in this revolutionary procedure that affords women the opportunity to use their own tissue to reconstruct their breast, while also hiding scars and improving their thigh aesthetics. Though the abdomen/DIEP flap is typically the best option, it is not the only option because of this revolutionary procedure. Please discuss this with Drs. Bailey or Morton at your consultation.