DIEP flap reconstruction for breast cancer patients

Tissue from the abdomen is marked for DIEP flap transfer.

Skin is undermined to allow skin closure.

The blood supply to the DIEP flap is identified.

The blood vessels are traced through the muscle and divided. The DIEP flap can now be transferred to create a new breast.

The abdomen is closed, and a new belly button created.

The DIEP flap taken from the abdomen is shaped into a breast.

The blood vessels of the chest and DIEP flap are joined together under a microscope.

You may prefer to have your mastectomy first and wait for your breast reconstruction. In many cases however the reconstruction can be done immediately with the mastectomy. The advantage of an immediate approach is that your own skin can preserved over the DIEP flap. The DIEP skin paddle is larger in the delayed group as the mastectomy skin flaps are not preserved. This difference in appearance is illustrated in the figure below on page.

Immediate mastectomy / reconstruction

Delayed reconstruction

To undergo a DIEP flap breast reconstruction you need to have sufficient abdominal tissue. Having had a C-section to give birth does not prevent you from having a DIEP flap. If you have previously had open or laparoscopic abdominal surgery, you will need to have a CT angiogram, a type of X-ray, to check if the blood vessels are present.

Studies have shown that for patients with a high BMI weight (above 30), there is a higher risk of complications with DIEP flap surgery. For example, the wound can break down and become infected. Occasionally, we do perform immediate reconstructions for patients with a BMI of up to 35 but you would be advised of the increased risk. If you have opted for a delayed reconstruction, we would advise you to achieve a BMI weight of less than 30.

You will need to have some routine blood tests and a CT scan of your abdomen to check whether you have an adequate blood supply for the DIEP flap.

We usually wait four to six weeks after chemotherapy has finished before performing a mastectomy and DIEP breast reconstruction.

You will usually have to wait for around 12 months after radiotherapy for a DIEP breast reconstruction as evidence points to lower complications and flap failure rates.

Your in-patient stay can be up to five days but in many cases you may be well enough to go home after three days.

On the first night after your operation, the DIEP flap breast reconstruction is checked frequently. This can often be the most sleepless and difficult night. After 48 hours, these checks are less frequent.

On the second day, most patients will have their urinary catheters removed. This is a tube used to empty the bladder into a bag. You are also likely to be sitting up out of bed and able to walk around the ward. Small plastic tubes placed underneath the skin of the abdomen where the surgery was performed, called pain catheters, are used to relieve pain, and are usually kept in for 48 hours.

DIEP breast reconstruction is the biggest operation you will undergo in the journey to rebuild your breast after cancer. Depending on what you want in terms of size, we often try to match the new breast with the existing one. This sometimes is not possible and smaller secondary procedures are needed.

Patients will often need a second operation to reduce and lift the existing breast, called a breast reduction or mastopexy. If there are any irregularities in the shape of the reconstructed breast, these can also be addressed in smaller operations.

Illustration above shows patient has had a left breast uplift to match her right DIEP reconstruction.

There is a one to four per cent risk of total failure of the reconstruction; this is usually due to a blockage in the blood vessels that are connected to the chest. This risk is increased in patients with a high BMI weight. There are also risks of infection, wound breakdown at the breast and abdomen and poor scarring.

Some patients will need to go back to theatre in the acute period for any of these risks and also if there is compromised blood supply of the DIEP flap. In rare cases you may get an abdominal bulge called a hernia due to a weakness in the abdominal wall. If troublesome it may require surgery.

Nipple reconstruction can be performed as the final stage of the breast reconstruction journey after your DIEP flap surgery. A new nipple can be made from local tissues over the DIEP flap under a local anesthetic. Once the new nipple has healed the areola, the small circular area around the nipple, can be tattooed to match the existing breast. If the colour fades, this procedure can be repeated.

Illustration above shows how skin is reshaped to make a new nipple.