What is a deep inferior epigastric artery perforator (DIEP) flap procedure?

Stuart A. Linder, MD
Plastic Surgery

The DIEP flap is one of the most advanced forms of breast reconstruction. The skin and fatty tissue are taken below the umbilicus as in an abdominoplasty to recreate the breast fullness after a mastectomy. The rectus abdominis muscles are spared and therefore there is no loss of abdominal muscle activity. The flap is removed as a "free-flap" and through microvascular surgery is attached to vessels in the breast areas. Many of the patients may also have sensory nerve reconstruction. 

Ajay K. Sahajpal, MD
Transplant Surgery
A DIEP (deep inferior epigastric perforators) flap procedure is a breast reconstruction surgery where the surgeon uses skin and fat tissue from the lower abdomen to reconstruct the breast.  The muscles of the abdomen remain intact.
A DIEP is a tissue transfer from the lower abdomen (tissue between the belly button and the pubic region) that spares the underlying abdominal muscles. It is most commonly used in reconstruction of the breast after mastectomy. The donor site is then closed in a manner similar to a "tummy tuck" leaving a low horizontal scar on the abdomen and around the belly button.

The blood vessels that keep this tissue alive are left attached to the harvested DIEP flap. These vessels arise from the deep inferior epigastric vessels, travel through the abdominal muscle, and spread out in the fat and skin over the muscle. (Hence the name of the flap). In order to keep the tissue alive, however, the vessels must be sewn into a recipient vessel at the defect site (using microsurgical techniques) to re-establish flow in and out of the tissues. In the case of breast reconstruction, the most common vessels that the DIEP flap is sewn to are the internal mammary vessels, which run underneath the cartilage between the rib and the sternum (breast bone).

The benefit of the DIEP flap over traditional abdominal flaps (such as the TRAM flap) include sparing of the body's core muscles. Particularly in cases of bilateral breast reconstruction, if both muscles are taken the abdomen is reconstructed with mesh, has a high risk of bulge, and takes away the ability to perform a sit up (when both muscles are gone). A true DIEP will trace the course of the vessel through the muscle, deliver it from the muscle, then leave a functional and viable muscle in place. The goal is to decrease the morbidity (damage) at the donor site while maximizing as much as possible the restoration of the acquired defect. In the case of breast cancer, restoring the form of the breast while diminishing donor site complications can be of high value in a patient already suffering from cancer.

Using excess and unwanted abdominal tissue to reconstruct a breast is an attractive option to many patients. It is important to discuss with a board-certified plastic surgeon trained in these techniques whether your disfigurement can be addressed with a DIEP flap and if you are a candidate for such a procedure.

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