Answers From Dr. Wise About DIEP Flap Reconstruction

Consultation with physicians at the Center for Restorative Breast Surgery involves a lengthy discussion during which an extensive medical history is gathered and a thorough explanation of the options for breast reconstruction are reviewed. This helps us participate in shared decision-making with the patient on what is the best option for breast reconstruction for a given individual. One of the most common procedures we perform for breast reconstruction is the DIEP flap. Below are some of the more frequently asked questions (with answers) that patients may have about whether or not they are candidates for DIEP flap breast reconstruction.

Who is a candidate for DIEP flap breast reconstruction?

Fortunately, most women are candidates for DIEP flap breast reconstruction. The surgery involves transplanting tissue from the lower part of the abdomen (usually from around the belly button to the bikini hairline) to rebuild the breasts at the time of mastectomy (immediate reconstruction) or at some time after the mastectomy (delayed reconstruction).

If I have had previous abdominal surgery, such as a C-section or a hysterectomy, am I a candidate for DIEP flap breast reconstruction?

Patients with previous abdominal surgeries almost always remain candidates for DIEP flap breast reconstruction. C-section and other “bikini-line” scars may even be beneficial by causing some of the blood flow that would typically come through that skin to reroute through the DIEP vessels. Gallbladder surgery, appendectomy, tubal ligations, and other common abdominal surgeries rarely affect a patient’s candidacy for the DIEP flap procedure. Tummy tucks (abdominoplasties) are the only surgery that precludes DIEP flap surgery. Other surgeries such as hernia repairs and extensive abdominal liposuction are evaluated on a case-by-case basis. All of our patients have a thorough exam of the abdominal donor area, Doppler ultrasound exam of the DIEP flap vessels, and often a CT Angiogram (CAT scan).

Is there an age limit for performing DIEP flap breast reconstruction (i.e. Can patients be too old or too young for surgery?)

While the majority of patients undergoing DIEP flap surgery are in their 30s to 60s, there is no age cutoff on either end. As people are living longer, healthier lives, it is not uncommon to see individuals in their 70s who are energetic and active and interested in pursuing breast reconstruction. Much more important than age is overall physical health.

Should I gain weight prior to my DIEP flap breast reconstruction?

For the majority of patients, the answer to this question is no. Because weight gain occurs fairly uniformly over the entire body, it does little to add volume to the abdomen and instead makes closure at the donor site tighter and more prone to problems. Mild weight loss at the recommendation of your reconstructive surgeon can occasionally be beneficial in providing added laxity and improved abdominal contouring and scar placement with the surgery. Overall, our general recommendations are to maintain a healthy diet in preparation for surgery.

Are patients who have failed implant reconstruction or who are unhappy with their implant reconstruction candidates for DIEP flap breast reconstruction?

Patients who have failed implant reconstruction, whether they have implants or tissue expanders in place, are often great candidates for DIEP flap breast reconstruction. The process involves removing the current implant or expander, restoring normal anatomy (replacing the pectoralis muscle back on the chest wall), and then rebuilding the breast with the transplanted abdominal tissue.

Do you offer DIEP flap breast reconstruction to smokers?

Nicotine use in all forms is strongly discouraged. We approach surgery for smokers on a case-by-case basis. We will usually offer reconstruction to smokers with active cancers because of the urgent need for treatment and the superior aesthetic results achieved with immediate reconstruction. All smokers are encouraged to quit prior to surgery. Delayed reconstruction cases, however, are approached individually with a thorough discussion of the adverse effects of nicotine on wound healing, blood flow, and other complications.

Are patients with blood clotting disorders (hypercoagulable conditions) candidates for DIEP flap breast reconstruction?

DIEP flap surgery is a microsurgical procedure that involves suturing vessels 2-3mm in size. These vessels are small, and clot formation in the vessels can lead to loss of the reconstruction. That being said, the majority of patients with blood clotting disorders are candidates for DIEP flap reconstruction. We work in conjunction with hematologists to customize a medical regimen to prevent clotting in the flap, as well as preventing DVT’s and pulmonary emboli. Our success rates in hypercoagulable patients are identical to the general population and are >99%.

Are patients with genetic diagnoses (such as BRCA1 and BRCA2) candidates for DIEP flap breast reconstruction?

Patients with genetic diagnoses are often ideal candidates for DIEP flap breast reconstruction and treated almost identically to patients with active disease. If they have an adequate abdominal donor site and no other absolute contraindication to DIEP flap surgery, then they are candidates.

Are there any specific patients who are not candidates for DIEP flap breast reconstruction?

There are very few patients who are not candidates for DIEP flap breast reconstruction. We often see patients who were told they were not candidates somewhere else, and after reviewing photos, talking with the patients, and examining them, many of them are indeed candidates. The few patients who are not candidates are listed below. The good news is that, even for these patients, options to use patients’ own tissue are readily available, as well as options for implant reconstruction or a combination of tissue and implants.

1. Patients who have had a previous tummy tuck (abdominoplasty) or previous TRAM flap for breast reconstruction are usually not candidates for DIEP flap surgery.
2.  Extremely thin patients may not have enough tissue to perform an adequate reconstruction, especially if they are thin and have not had children.
3. Medically unstable patients may not be healthy enough to undergo a 4-8 hour operation.

For the majority of patients who have had a previous abdominoplasty, or who are very thin, there are other options for breast reconstruction readily available. Those include: GAP/Hip flaps from the upper buttock, TUG/PAP flaps from the inner thigh, or TDAP flaps from the upper back, as well as implant-based breast reconstruction. Also, it may be possible to do a DIEP flap reconstruction combined with an implant to add additional volume and projection in the thin patient.

How can I find out more about DIEP flap breast reconstruction?

If you are looking for more information on the procedure, there are many great resources on our website. These include: anatomic diagrams, descriptions of the procedure, and before-and-after pictures. Finally, please give us a call or fill out the information form and we can contact you personally to discuss any questions or concerns you may have.