DIEP flap

Deep inferior epigastric artery perforator (DIEP) flap is a type of breast reconstruction surgery that uses a woman’s own abdominal fat, skin, and blood vessels to rebuild the breast or breasts after mastectomy. The tissue used to create a new breast is called a flap.

DIEP flap is one of several breast reconstruction options. Another option is implant reconstruction, which involves placing a breast implant above or under the chest muscle and skin after mastectomy. Many women who undergo DIEP flap experience more satisfaction with the way their breasts look than with other reconstruction options. Still, compared to implant-based reconstruction, tissue reconstruction generally requires a longer surgery, a longer hospital stay, and a longer time to get back to your normal activities.

On this page, we’ll explain what’s involved in a DIEP flap surgery and what to know about eligibility, side effects, complications, and insurance coverage.

What is DIEP flap surgery?

DIEP flap surgery uses a person’s own abdominal tissue to create a new breast or breasts. Unlike some other flap procedures, DIEP flap does not remove any muscles from the abdomen — just skin, fat, blood vessels, and nerves.

Some older flap reconstruction procedures, called pedicled flaps, leave the donor tissue attached to its blood supply and tunnel the tissue and blood vessels under the skin to the chest. In contrast, other flap reconstructions, including DIEP flap, completely remove the tissue from its original location and move it to the chest (a “free flap”).

Perforator flaps, including DIEP flap, use advanced techniques and have fewer side effects than other techniques because they do not remove muscle.

DIEP flap reconstruction is performed by specially trained plastic surgeons called microsurgeons. Microsurgeons use special instruments and microscopes to work with blood vessels during this surgery.

DIEP flap reconstruction can be performed immediately after mastectomy, or later (delayed reconstruction). If you’re deciding between immediate or delayed reconstruction, talk with your reconstruction surgeon about other treatments you may be having, such as chemotherapy and radiation therapy, because these can have an impact on reconstruction timing and outcome.

Who can get a DIEP flap?

With some exceptions, nearly anyone with enough abdominal fat to build one or two new breasts can get DIEP flap reconstruction after mastectomy. In the United States, it’s the most commonly performed tissue-based reconstruction.

• Of women choosing any type of breast reconstruction, including implant-based reconstruction, 17% choose DIEP flap.
• Of women who choose to have any type of tissue reconstruction, 83% choose DIEP flap.

Different breast reconstruction surgeons may have different requirements for how much abdominal fat is needed to perform DIEP flap surgery. With some approaches, women who are very thin and have little abdominal fat are not considered to be candidates for this surgery. In other cases, different planning, techniques, and incisions may be used to make DIEP flap possible for women who do not have much abdominal fat.

Previous abdominal surgery and DIEP flap eligibility

Some women are not eligible to have a DIEP flap procedure because of certain previous abdominal surgeries:

• Women who have had a prior abdominal tissue breast reconstruction, such as DIEP or TRAM flap; there may not be enough fat, skin, or blood vessels left in the abdominal tissue to perform a second procedure, so a different type of flap procedure would be recommended
• Women who have had a standard tummy tuck, because this procedure removes fat previously connected to blood vessels and can also damage blood vessels; if you gain weight later, the fat would not be in the required location for a DIEP flap
• Women who have had other abdominal operations that have affected the blood vessels required for DIEP flaps

Not all past abdominal surgeries prevent a woman from having DIEP flap reconstruction. If you’ve had a mini tummy tuck, a C-section, a hysterectomy, liposuction, or an appendectomy, you may still be a candidate for a DIEP flap.

And while prior surgeries can sometimes injure the blood vessels required to do DIEP flap surgery, in many cases, these blood vessels are not affected, and DIEP can still be performed.

Let your surgeon know if you’ve had abdominal surgery in the past. Your surgeon will evaluate your blood vessels using imaging to make sure DIEP flap is an option.

Some medical conditions and lifestyle factors can affect DIEP flap eligibility

There are medical and lifestyle factors that may make DIEP flap reconstruction difficult or less likely to succeed, and may be a reason to choose another reconstruction technique. These include:

• Having uncontrolled diabetes, poor circulation, or connective tissue diseases that compromise wound healing, shrink or reduce blood vessels, or interfere with blood supply to the new breast and abdomen
• Smoking, which constricts blood vessels and can cause delayed wound healing, blood clots, thick scars, infection, and lumps caused by the death of fat cells; smoking can also lead to anesthesia-related lung complications, such as pneumonia, during this several-hour surgery

As you make decisions about DIEP flap reconstruction, visit any potential surgeons in person so you can have a physical examination. Let them know if you have any of these conditions or if you smoke. An in-person exam can help you and the surgeon confirm whether DIEP is the right procedure for you.

What happens during DIEP flap surgery

DIEP flap surgery can take 6 to 8 hours. During surgery, microsurgeons remove fat, skin, and blood vessels from the abdomen and place them in the chest to create a breast form.

The procedure requires two surgical incisions:

• One incision on the lower abdomen, from hip to hip below the navel within the bikini line
• Another incision on the chest where the breast will be built (two if you’re having both breasts reconstructed)

Microsurgeons use a microscope to clearly see each blood vessel that they cut, move, and reconnect to blood vessels in the breast area. Correctly connecting the blood vessels during DIEP flap surgery is key to the surgery’s success, because the moved tissue needs good blood supply to remain healthy.

In some cases, microsurgeons can also move a sensory nerve with the abdominal tissue. Some women report better sensation in the rebuilt breast when a nerve can be moved and reconnected to nerves in the chest that were cut during mastectomy. There is also evidence showing that nerve regeneration can happen after flap reconstruction with natural tissue.

Another option for some people is a procedure called Resensation. It uses a nerve graft made from donated human nerve tissue that connects chest nerves to tissue flap nerves. Over time, the graft guides the nerves to grow together. The goal is to restore feeling. To learn more, visit Breast reconstruction.

The surgeon will also place a drain in each incision to help remove fluid and lessen swelling over the first few weeks of recovery. Later on this page, we’ll talk about caring for drains at home after surgery. Drains are eventually removed by the surgeon.

There is a low risk of blood clots during DIEP flap surgery. If the blood vessels become blocked by a clot, the surgery will not work. Blood clots can happen if:

• There is injury to the donor tissue as it’s being removed from the abdomen; this risk is extremely low if experienced microsurgeons perform the surgery
• You have a genetic mutation that elevates clot risk

Talk with your surgeon about these and any other risks.

Recovery from DIEP flap surgery

One of the benefits of DIEP flap surgery is that its recovery time tends to be shorter than recovery from other types of tissue reconstruction because it avoids cutting muscle.

Still, it’s important to know that recovering from DIEP flap surgery takes longer than recovering from implant reconstruction. A non-medical reason that some people choose to do implant reconstruction instead is because they do not have enough time to recover slowly from a flap procedure.

Here’s what to expect after DIEP flap surgery

Immediately after surgery you’ll be taken to a hospital room, where your care team will monitor your recovery. Most people will stay in the hospital for 2-5 days after DIEP flap surgery.

Recovery at home can take anywhere from 3 to 8 weeks, though everyone’s experience is different.

Remember that two areas of your body will be recovering – your abdomen and your chest. Recovery at the hospital and at home will focus on both areas.

There will be a drain in each incision to help remove fluid and lessen swelling.

• Drains are small tubes temporarily sewn into the chest, under the arm, and into the abdomen to allow fluid to leave the incision. The drains help reduce the risk of infection from fluid build-up. This helps wounds heal faster.
• You or a caregiver will need to keep the drains clean to avoid infection; a nurse will show you how to do this before you leave the hospital, as well as how to measure how much fluid the drains are removing from your body.
• How long you have the drains depends on how long it takes your body to produce less fluid for the drains to collect. Typically, your surgeon will remove the drains around 2 weeks after surgery.

Your surgeon may ask you to wear compression garments, or binders, after surgery. Compression garments are tight-fitting, elastic clothing specially designed to put pressure on surgical areas to support tissues and lessen swelling.

• Your hospital may provide you with a compression garment or they may recommend a garment or garments you can buy.
• How long you’ll wear compression garments can vary from 2 to 8 weeks, depending on your situation and surgeon’s recommendations.

Some women choose to sleep in a recliner the first few days after surgery to keep from rolling over onto surgery wounds, or they may sleep with pillows under their knees.

As you heal, you’ll be able to add more movement to your day, working up to what you could do in the past. Your arm muscles directly impact the muscles of your chest, so you’ll need to work slowly, and your care team will advise you on movements such as lifting or reaching overhead.

Driving will be restricted while you take pain medication and while your abdominal wound heals.

You may need to wait 6-8 weeks before returning to exercise, though walking frequently is recommended to help avoid blood clots.

When to call your doctor

Call your doctor if you develop any of the following:

• Increased swelling
• Increased bruising
• Pain that doesn’t go away with medicine
• Swelling and redness along the incision that won’t go away after 1-2 days
• A fever of 100.4 degrees or more
• Green or yellow fluid coming from the incision, or fluid that smells bad
• Bleeding that does not stop with light pressure
• New loss of feeling or motion

These other symptoms can be side effects of medicine you may be prescribed. Call your doctor if you have:

• Rash
• Nausea
• Headache
• Vomiting

Questions to ask your doctor

• What should I do to prepare for surgery?
• Is there anything I need to bring to the hospital with me?
• What type of clothing should I bring for after surgery?
• Do I need to wear a bra after surgery? Will my hospital supply one to me?
• Can I drive myself home after discharge?
• How long do I need to wear compression garments?
• How do I clean my surgical drains?
• When can I take a shower?
• Am I allowed to lift heavy things/groceries/my baby? When can I start?
• Do I need physical therapy?
• When should my breasts have their “final look” (no swelling, redness, etc.)
• Who do I call if I experience complications or side effects?
• If having a family is important to me, can I still get pregnant and have a vaginal delivery after DIEP flap surgery?

DIEP flap post-surgical side effects

Post-surgical side effects are unintended issues caused by surgery. In reconstructive surgery, a side effect is any result beyond moving tissue and rebuilding the breasts, such as pain, scarring, or infection.

Side effects can be short-term, meaning they appear right after surgery and last only a few days to weeks, or long-term, meaning they appear soon after surgery but can last months to years.

The short-term side effects of DIEP flap surgery can include:

• Pain and tightness in the breast, chest, armpit, and any donor tissue sites used in breast reconstruction, such as the abdomen
• Swelling that is temporary
• Limited range of motion
• Bleeding at a surgical incision
• Infection
• Temporary loss of sensation of the breast; while some permanent numbness does happen, a lot of sensation can be recovered, depending on the amount of under-the-skin nerves preserved during mastectomy

The long-term side effects of DIEP flap surgery include:

• An increased risk of developing lymphedema , a buildup of fluid in the hand, arm, breast, chest wall, or torso on the side you had surgery, particularly if you had lymph node removal (sentinel node biopsy or axillary lymph node dissection), mastectomy, and DIEP flap surgery performed together
• Long-term lymphedema
• Scar tissue at the site of the operation, which can be stiff, a different color than the person’s overall skin tone, and irregularly shaped

All tissue flap surgeries leave scars where tissue was taken, as well as a scar on the reconstructed breast. These scars don’t go away, although they do lessen over time.

DIEP flap complications

The overall risk of post-surgery issues is relatively low with DIEP flap reconstruction, whether you have one breast reconstructed or both. Your surgical team can help you manage issues if they happen.

Unlike side effects of surgery, such as pain at the surgery site, loss of motion, and formation of scar tissue, complications of surgery are serious medical issues that develop after surgery. Like side effects, complications can be short-term or long-term, and some can be late (developing months to years later). Below is a list of short- and long-term complications that can happen after DIEP flap reconstruction, and how common each may be.

Short-term complications of DIEP flap reconstruction

Short-term complications — complications that develop soon after surgery but can be resolved in days or weeks — can include:

• Blood clot: A mass of blood that sticks to the wall of a blood vessel, potentially blocking it. Your care team may try to prevent blood clots, or treat them if found, by prescribing medicine to temporarily thin your blood.
• Hematoma: A pool of blood that collects in an organ or tissue, causing swelling and sometimes pain. Hematomas can go away on their own or may need surgery.
• Abdominal muscle weakness: Weakness that can happen if muscle fibers are split to retrieve blood vessels, which can also impact nerves that power the muscle; weakness is temporary as the muscle and nerves recover
• Abdominal bulge: A noticeable, but small, lump that forms during activities that contract the abdominal muscles
• Hernia: A condition in which part of an organ bulges through a weak portion of muscle, usually in the abdomen

Long-term complications of DIEP flap reconstruction

Long-term complications — complications that develop after surgery and can last months or years — can include:

• Scar tissue that forms lumps, either on the abdominal scar or the breast scar. They can go away on their own or be removed by a doctor.
• Partial or total flap loss, a situation in which the tissue moved to the breast does not get enough blood flow and part or all of it dies. Areas of tissue that fail to thrive need to be surgically removed. The risk of partial flap loss is about 1%; the risk of total flap loss is about 2%. If flap loss happens, it’s still possible to have revision reconstruction to correct it. You may need to wait several months to heal before having revision surgery.
• Fat necrosis, or death of tissue that forms lumps of fat in the breast. Necrosis may occur right after surgery if the blood vessels develop clots in them. All tissue-based reconstructions have a small risk for necrosis. Larger flaps, previous abdominal surgery, and radiation therapy can increase the risk of fat necrosis. Dead tissue needs to be removed by a surgeon.

Delayed vs. immediate DIEP flap reconstruction complications

When you’re making decisions about breast reconstruction, you have the choice between immediate reconstruction or delayed reconstruction.

• In immediate reconstruction, mastectomy is performed at the same time as breast reconstruction.
• In delayed reconstruction, surgery to reconstruct the breast is performed months or even years after mastectomy.

Recent research shows that immediate and delayed DIEP flap surgery are equally safe and have nearly equal rates of surgical complications. The study found that the only complications that differed between immediate and delayed DIEP surgery were with wound healing, such as a wound breaking open, skin necrosis, the wound taking more than 30 days to fully heal, or wounds that required some revision surgery. Overall, the researchers found that these wound issues were more common in people who had delayed DIEP flap surgery.

DIEP flap reconstruction and radiation therapy complications

Some breast cancer treatment plans require radiation therapy after surgery, and whether you need radiation can play a role in your choice of immediate or delayed DIEP flap surgery. One study found that radiation after DIEP flap surgery resulted in more occurrences of flap tissue shrinkage and irregular scarring, while another found that radiation after DIEP flap surgery led to higher rates of fat necrosis and fibrosis (fibrous tissue forming at the surgery site). All of these can impact the way reconstructed breasts look.

If radiation therapy is part of your treatment plan, talk with your breast reconstruction surgeon and your radiation oncologist about timing that works best for both treating the cancer and having a good reconstruction outcome.

Unilateral vs. bilateral DIEP flap reconstruction complications

Another decision you may need to make is whether to have one or both breasts reconstructed. You’re likely to make this decision when you’re thinking through whether to have both breasts removed (double mastectomy). Reasons people choose double mastectomy include:

• Having breast cancer in both breasts
• Having a high risk of breast cancer returning
• Wanting to lower the risk of breast cancer returning
• Testing positive for a high-risk inherited breast cancer mutation such as BRCA1 or BRCA2

Depending on how much abdominal fat you have, DIEP flap reconstruction can recreate one or both breasts. According to a 2017 study in the Annals of Surgical Oncology, the risks increased when DIEP flap surgery reconstructed two breasts instead of one. Researchers don’t know for sure why risk might increase, but they suggest that removing more tissue from the abdomen, and surgeons becoming tired during longer surgeries, may play roles.

According to breast reconstruction surgeon Jonathan Bank, MD, “More surgery means more risk, but in general the risks are manageable and bilateral DIEP flaps remain more common than unilateral ones.”

Paying for DIEP flap surgery

Federal law requires insurance companies to cover breast reconstruction, including DIEP flap surgery. Still, out-of-pocket expenses can vary significantly based on individual policies.

If you are concerned about paying for DIEP flap surgery, talk with your healthcare team. Many cancer centers have financial counselors who can help you plan and find resources. You can also visit our Financial matters section for information on managing costs, finding assistance, and managing your insurance.