Breast Care A-Z · Procedure · DIEP

DIEP flap

also: Deep Inferior Epigastric Perforator flap, DIEP reconstruction, DIEP flap reconstruction, autologous abdominal flap reconstruction · pronounced DEEP (one syllable, rhymes with 'keep')

DIEP flap reconstruction is one of the main alternatives to implant-based reconstruction after mastectomy.

Quick answers

How long does DIEP flap surgery take?

Most DIEP flap operations take six to eight hours for a single breast. Bilateral DIEP — reconstructing both breasts at the same time — usually takes eight to ten hours.

Is DIEP reconstruction done at the same time as the mastectomy?

It can be, if the cancer treatment plan supports it and the hospital has the microsurgical team available. This is called immediate reconstruction. It can also be done as a separate, later operation, which is called delayed reconstruction.

Is DIEP reconstruction available on the NHS?

Yes, DIEP flap reconstruction is available on the NHS at specialist centres with the microsurgical capacity to perform it. Waiting times and the choice between immediate and delayed reconstruction vary by trust.

DIEP Flap -- Breastory Encyclopaedia Plate LXIX Plate covering deep inferior epigastric perforator flap breast reconstruction: anatomy, surgical steps, comparison with TRAM and LD flaps, and outcomes. SURGERY · RECONSTRUCTIVE PROCEDURES PLATE LXIX DIEP flap deep inferior epigastric perforator flap · microsurgical breast reconstruction microsurgical transfer of abdominal skin and fat on perforator vessels, reconstructing the breast without sacrificing abdominal muscle — the gold standard autologous technique FIG 01 — DIEP flap anatomy and microsurgical transfer DONOR SITE — Abdomen rectus abdominis flap harvest zone (skin + fat, no muscle) DIEA (deep inf. epigastric a.) perforator flap transfer RECIPIENT SITE — Chest IMA internal mammary vessels (recipient) anastomosis (DIEA → IMA) reconstructed breast mound warm, soft, natural i — deep inferior epigastric artery (DIEA) perforator ii — abdominal skin + fat (flap — no muscle taken) iii — intramuscular perforator dissection (muscle-sparing) iv — microsurgical anastomosis to internal mammary vessels (IMA) v — reconstructed breast mound: warm, soft, natural tissue Preoperative planning CT angiography to map perforators Dominant perforator identified by calibre Flap design marked on abdomen 6–8 hour operation Specialist microsurgery team required Advantages over TRAM flap No muscle taken no abdominal weakness post-op Faster recovery less donor-site morbidity No hernia risk TRAM abdominal hernia ~5% FIG 02 — DIEP vs TRAM vs LD flap: 10-point comparison Parameter DIEP TRAM / LD Muscle sacrifice None Rectus abdominis / Latissimus dorsi Abdominal weakness Minimal 10–20% (TRAM) / None (LD back) Op time 6–8 hours 5–7 hours / 3–4 hours Microsurgery Yes (free flap) Free or pedicled / No (pedicled) Hospital stay 5–7 days 5–7 days / 3–5 days Implant supplement Rarely needed Sometimes / Often Volume Large Large / Moderate Donor scar Lower abdominal (bikini) Lower abdominal / Back Failure rate ~2–3% ~2–5% (free TRAM) / <1% (LD) Best use Abdominoplasty harvest, post-RT Alternative / Implant failure FIG 03 — DIEP flap surgical steps Step Description Key consideration Pre-op CT angiography Perforator mapping Identify dominant perforators Patient positioning Supine, arms out Dual-team approach Flap design Ellipse marked on abdomen Stay within Scarpa's fascia Perforator dissection Intramuscular dissection Preserve rectus muscle Flap harvest Skin-fat island on perforators DIEA pedicle 8–10 cm Recipient vessels Internal mammary vessels exposed IMA/IMV via rib cartilage Microsurgical anastomosis DIEA to IMA (artery + vein) 8-0 nylon microsurgery Flap shaping Breast mound formed Match contralateral volume Closure Abdominoplasty-type closure Scarpa's preserved for lymphatics FIG 04 — DIEP flap reconstruction pathway 1 Mastectomy decision + autologous flap preference 2 CT angiography (perforator mapping) 3 Pre-op planning + abdominal marking 4 DIEP harvest + microsurgical transfer (6–8 hours) 5 ITU/HDU overnight: hourly flap checks 6 Nipple reconstruction + lipofilling (3–6 FIG 05 — DIEP flap variants and planning tools DIEP flap (standard) Bilateral DIEP (both breasts) Stacked DIEP (extra volume) SIEA flap (superficial variant) Delayed DIEP (post-RT) CT angiography perforator planning FIG 06 — Key statistics Flap success rate >95% [1] No significant abdominal muscle weakness vs controls [2] >85% long-term patient satisfaction (BREAST-Q) [3] Gold standard for post-radiotherapy reconstruction [4] References 1. Gill PS et al. 758 consecutive DIEP flaps. Ann Plast Surg 2004 2. Blondeel PN et al. Abdominal wall function after DIEP. Plast Reconstr Surg 1997 3. Yueh JH et al. BREAST-Q outcomes DIEP. Plast Reconstr Surg 2010 4. Spear SL et al. DIEP in previously irradiated. Plast Reconstr Surg 2005 5. NICE NG101. Early breast cancer 2023 Clinically authored by Dr Fiona Tsang-Wright , FRCS (Gen Surg) GMC 4549831 · ORCID 0000-0003-4801-026X
Visual Reference · DIEP flap
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Definition
A DIEP flap is a type of breast reconstruction that rebuilds the breast using skin and fat from the lower abdomen, transferred with its own blood supply and without removing any abdominal muscle.
0% Abdominal muscle taken (DIEP preserves it; the older TRAM flap does not) 2
~6 hrs Typical operative time for a single-side DIEP reconstruction 1

Common questions The questions patients ask first

How long does DIEP flap surgery take?
Most DIEP flap operations take six to eight hours for a single breast. Bilateral DIEP — reconstructing both breasts at the same time — usually takes eight to ten hours.
Is DIEP reconstruction done at the same time as the mastectomy?
It can be, if the cancer treatment plan supports it and the hospital has the microsurgical team available1. This is called immediate reconstruction. It can also be done as a separate, later operation, which is called delayed reconstruction.
Is DIEP reconstruction available on the NHS?
Yes, DIEP flap reconstruction is available on the NHS at specialist centres3 with the microsurgical capacity to perform it. Waiting times and the choice between immediate and delayed reconstruction vary by trust.
Will I still be able to do abdominal exercise after a DIEP flap?
DIEP preserves the abdominal muscles, so core strength is usually retained. Most patients return to their previous exercise tolerance by around three1 months; abdominal exercises are reintroduced gradually from six weeks under physiotherapy guidance.

A DIEP flap is a type of breast reconstruction that rebuilds the breast using skin and fat from the lower abdomen, transferred with its own blood supply and without removing any abdominal muscle.

DIEP stands for Deep Inferior Epigastric Perforator1 — the name of the small blood vessels that keep the transferred tissue alive. The operation is usually offered to patients who need or have already had a mastectomy and want a reconstruction that uses their own tissue rather than an implant. It is a microsurgical operation, typically taking six to eight hours.

Orientation Why you might be reading about this

DIEP flap reconstruction is one of the main alternatives to implant-based reconstruction after mastectomy. Patients usually encounter the term when their surgeon is explaining reconstruction options, when they are reading about recovery after breast cancer surgery, or when they are deciding between reconstruction now and reconstruction later. Understanding what a DIEP flap is — and what it is not — makes the conversation with your surgeon more productive.

Related terms: Mastectomy · Immediate reconstruction · Delayed reconstruction · Implant reconstruction · TRAM flap · PAP flap · Microsurgery · Free flap

The procedure How the operation works

During a DIEP flap reconstruction, a section of skin and fat is taken from the lower abdomen — roughly the area that a tummy tuck would remove — along with one or two small blood vessels (perforators) that supply it. No abdominal muscle is taken. The tissue is moved to the chest and its blood supply is reconnected, under an operating microscope, to vessels in the chest wall, usually the internal mammary artery and vein. The new breast is then shaped from the transferred tissue.

The distinction from the older TRAM flap is important. A TRAM flap takes part of the abdominal muscle with the tissue, which weakens the abdominal wall. DIEP preserves the muscle, which is why it has become the standard of care for autologous breast reconstruction in centres with the microsurgical capability to perform it.

Suitability Who it is suitable for

DIEP flap is usually considered if you have enough tissue on the lower abdomen1 to build a breast of the size you want, do not smoke (or can stop for a window of around eight weeks around the surgery), and do not have medical conditions that would make a long operation unsafe. Previous abdominal surgery may or may not rule it out, depending on where the scars sit and whether the perforator vessels have been divided.

It is not the right operation for everyone. Patients who are very slim may not have enough tissue; patients who have had certain abdominal surgeries may have had the perforators divided; and some patients prefer implant reconstruction, or no reconstruction at all, after discussing the trade-offs. Your surgeon should present all options, not just this one.

The choice Immediate versus delayed DIEP

A DIEP reconstruction can be done at the same time as the mastectomy (immediate reconstruction) or months to years later (delayed reconstruction). The decision depends on the stage of the cancer, whether radiotherapy is planned (radiotherapy after an immediate reconstruction can affect the reconstructed breast), and patient preference.

Recovery What recovery looks like

Most patients stay in hospital for five to seven nights, although enhanced recovery (ERAS) protocols at some specialist centres allow earlier discharge. The abdominal site is monitored as carefully as the chest site during that period. Bending and lifting are restricted for the first six weeks to protect the abdominal repair. Most patients return to desk work at around six weeks and to full activity, including exercise, at around three months.

At consultation Questions to take to consultation

If you are considering DIEP flap, it is worth asking your surgeon: how many DIEP flaps does the team perform each year; what is the flap-monitoring protocol in the first 24 hours; what are the alternative reconstructions available at this hospital; and what happens if the flap fails. You can read more about reconstruction options on the breast reconstruction services page.

DIEP specifically is described on the DIEP flap reconstruction service page.


Resources Further reading

Sources & guidance

Every figure on this page is anchored to a published source. Tap a number in the text or below to jump to the reference.

  1. guidance Royal College of Surgeons of England / Association of Breast Surgery. Oncoplastic Breast Reconstruction: Guidelines for Best Practice. London: RCS. 2021 https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/ Cited for: UK best-practice standards for oncoplastic and reconstructive breast surgery.
  2. patient NHS. Breast cancer in women. nhs.uk. 2024 https://www.nhs.uk/conditions/breast-cancer-in-women/ Cited for: Patient-facing context for reconstruction options; not used for clinical claims.