Free Flap (DIEP) Reconstruction

What is DIEP (Deep Inferior Epigastric Artery Perforator) Flap Breast Reconstruction Surgery?
A Deep Inferior Epigastric Perforator (DIEP) free flap is considered to be the gold standard plastic surgical technique for breast reconstruction. This ‘autologous’ procedure involves completely detaching excess tissue from the abdomen and transferring it to the chest to create a breast. In the abdomen there is an important muscle called the rectus abdominis muscle, which helps to stabilize the trunk, preventing herniation and allowing you to sit up. Overlying the muscle is a roll of soft tissue with the skin and fat. This area is essentially a spare part. The blood supply to the fat and skin comes through the muscle described above.

In the DIEP flap, we only take the fat roll from the abdomen with its blood supply and completely preserve the muscle. The muscle is therefore undamaged and it can continue to support the tummy as normal. In addition to the breast reconstruction you will have a tummy tuck or abdominoplasty as an added benefit.

As the flap is completely removed from its blood supply and then reattached in a different are. This is called a free flap.

An elliptical area of skin and fat is removed from your tummy by chasing the supplying blood vessels through your rectus muscle to the femoral vessels in your groin. The tissue is then completely removed and the artery and vein are reattached to small vessels under your arm. The rectus muscle is left completely intact. The abdomen is closed in the same way as a tummy tuck, leaving a horizontal incision in the lower abdomen and a small incision around your new umbilicus (belly button). Once the breast flap is reattached to its new blood supply it can be inset to create a breast. If you are having an immediate breast reconstruction with a skin-sparing mastectomy, then a small circular area of skin from your abdomen will be used to replace your nipple and areolar. The remainder of the breast skin will be preserved and the flap will sit underneath this replacing the breast tissue that was removed by the mastectomy.

If you have already had or are having a full mastectomy (which takes all the breast skin) then the skin will be replaced with a leaf shaped area of skin from your abdomen.

Your incisions will be closed with a dissolvable suture that does not need removing. You will have waterproof glue based dressing, which will gradually dissolve at about 3 weeks. You can shower as soon as you want and do not need any dressing changes.

A tube (called a drain) will drain off any excess blood or body fluid from your abdomen and breast.

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, no surgery is without risk and it is important that you are aware of these potential problems.

Scar – scars tend to settle remarkably well, however some people heal with thick scars and this can make them more noticeable.

Bruising and swelling – bruising and swelling is very common and may take several weeks to settle.

Haematoma – this can happen if a bleed occurs under the skin, allowing a large blood clot to form. If this does occur, it is likely to happen within four to six hours of surgery. Any increase in swelling or pain should be reported immediately so that treatment can be given. Sometimes patients need to have this blood removed with another short operation.

Infection – this is rare but you may require antibiotics if there are any concerns.

Seroma – this is a collection of clear fluid under the skin, which sits in a pocket. This spontaneously reabsorbs over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Flap failure – as the flap is relying on small blood vessels to keep it alive, there is a small chance the flap may not work. This is in the order of about 1% risk, so it is very uncommon. The flap may not be possible at the time of surgery or it may stop working within the first 24 hours. It is uncommon that you would have any problems after this. If a flap fails then another reconstructive option would be used.

Wound healing problems – this is rare but can happen if the skin is under tension or the blood supply to the flap has been damaged in any way. These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, such as area of skin loss. Although very rare, this situation may require a skin graft to close the wound, meaning more surgery. People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Fat necrosis – this occurs when small areas of fat within the flap have a reduced blood supply and scar leaving a palpable thickening under the skin. In most cases this settles with massage but it may require a further procedure to remove the fat.

Dog-ears – these are prominences of soft tissue found where the scar stops. In most cases these settle over the course of 3 months. However a small local anaesthetic procedure may be required to remove any excess that remains.

Numbness, reduced sensation or oversensitivity – this will occur around the scars. This is sometimes temporary, but for most patients these changes will remain to some degree.

DVT/PE – following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. In order to reduce any risks of this we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to ask. Decisions about surgery should never be rushed.

When you wake up from the anaesthetic, you will have a drain coming under your arm to remove any fluid collecting in your breast and two drains coming out from your abdomen. You will have dissolvable sutures with a glue and tape dressing.

The drains are removed at about 3 days and you should expect to be in hospital about 5-7 days.

You will need to wear a support bra and an abdominal corset to help shape your breast and support your abdomen as you are healing.

You should purchase a bra before your operation but an abdominal corset will be provided by the hospital. I can guide you as to the most appropriate bra in your consultation.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at a week to check your wounds. I would normally see you at 2 weeks or sooner should you have any problems.

Recovery times vary from one person to another but most patients return to work at 8-12 weeks. You can start driving at 2 weeks, commence gentle exercise at 4 weeks and return to the gym at 6 weeks.

Anne Dancey

I hope you find this information useful. If you have any questions or require a little more information then please do not hesitate to contact me.

Anne Dancey

Plastic and Reconstructive Surgeon FRCS(Plast), MBChB(Hons), MMedSci(Hons) and MCh(PASP)