What a DIEP flap is
DIEP stands for Deep Inferior Epigastric Perforator — the small blood vessels in the lower abdomen that keep the transferred tissue alive. A DIEP flap rebuilds the breast using skin and fat from the lower abdomen (roughly the area a tummy tuck would remove), transferred with its own blood supply and reconnected to blood vessels in the chest under an operating microscope.
Crucially, no abdominal muscle is taken — which is what distinguishes a DIEP from the older TRAM flap. Preserving the abdominal muscle reduces the risk of abdominal weakness, hernia, and long-term functional problems.
For a shorter, patient-level definition of the operation, see the DIEP flap glossary entry.
Further reading. A smaller-incision, robotic-assisted form of DIEP is used in some UK centres. That technique is explained separately by the London Robotic Breast Institute — an affiliated information resource. Robotic-assisted reconstruction in the UK. It is not a Breastory service.
Who DIEP is for
DIEP is a reconstruction option for patients who:
- Need or have already had a mastectomy (unilateral or bilateral)
- Have enough tissue on the lower abdomen to build a breast of an appropriate size
- Are non-smokers, or can stop smoking for a window around the surgery (smoking impairs the small-vessel circulation the flap depends on)
- Do not have medical conditions that make a long operation unsafe
- Want a reconstruction that uses their own tissue rather than an implant
Patients who might be better served by a different approach include those with very little abdominal tissue, those who have had previous abdominoplasty or certain abdominal surgery that has interrupted the blood supply, and those whose general health does not support a 6–8 hour operation.
DIEP can be done as an immediate reconstruction (at the same operation as the mastectomy) or as delayed reconstruction (months or years later). The choice depends on the stage of the cancer, whether radiotherapy is planned, and what you prefer.
DIEP compared with implant reconstruction
Both approaches have a place. DIEP is not “better” than implant reconstruction — they are different operations with different trade-offs.
DIEP tends to suit patients who value:
– A reconstruction that feels and moves more like a natural breast
– A result that ages with the body — it changes with weight and over time, as natural tissue does
– A reconstruction that tolerates radiotherapy better than an implant
– One larger operation now, rather than the possibility of further implant revisions later
Implant reconstruction tends to suit patients who value:
– A shorter operation (1–2 hours versus 6–8 hours) and a shorter recovery
– No second surgical site on the abdomen
– A more predictable operative timeline if they need to return to work or caring responsibilities quickly
This trade-off is the heart of the consultation, and most patients find that one option quite quickly feels like theirs. There is no wrong answer.
The operation
- Anaesthetic: general anaesthetic.
- Length of operation: typically 6–8 hours for a unilateral DIEP; longer for bilateral (both sides).
- Incisions: one along the lower abdomen (hip-to-hip, hidden by most underwear and swimwear), one on the chest where the flap is placed.
- What happens:
1. The skin and fat of the lower abdomen are raised on their perforating blood vessels.
2. Blood vessels in the chest are prepared — usually the internal mammary artery and vein.
3. The flap is transferred to the chest and the vessels are reconnected under an operating microscope.
4. The flap is shaped into a breast mound.
5. The abdomen is closed, with the umbilicus (belly button) repositioned to its new location. - Hospital stay: typically 5–7 nights, with some specialist units discharging on enhanced-recovery pathways from 4 nights.
The critical first 24 hours — flap monitoring
The reconnected vessels are just a few millimetres across, and a small clot or kink in the first 24 hours can compromise the blood supply to the flap. This is the period where outcome is actually protected, and it is the bit most patients do not see.
After surgery the flap is monitored continuously — typically hourly observations, specialist nursing, and direct flap checks. If any early sign of vascular compromise is picked up, the patient goes back to theatre promptly and the vessels are explored and corrected. This approach is the reason DIEP flap success rates in specialist units run above 97–98% in published series.
Choosing a unit with established flap-monitoring protocols is one of the most important predictors of a DIEP going well.
Revisions
Most DIEP reconstructions are refined with one or more smaller operations at 6–12 months — for symmetry, scar revision, nipple reconstruction where the nipple has been removed, and minor shaping adjustments. These are day-case or overnight procedures and are part of the reconstructive arc rather than a sign that anything has gone wrong.
Over the longer term, DIEP reconstructions typically do not need the recurrent revisions that implant reconstructions do.
Risks specific to DIEP
Every operation carries risk. Specific to DIEP, the risks include:
- Partial or total flap loss — uncommon in experienced units but serious. The flap-monitoring protocols above exist to catch early signs.
- Fat necrosis — firm lumps within the flap from areas of fat that did not get enough blood supply. Usually settles, sometimes needs surgical removal.
- Abdominal wall weakness or bulge — lower than with a TRAM flap because no muscle is taken, but not zero. Preserved by meticulous muscle-sparing technique.
- Delayed wound healing at the abdominal donor site — particularly in smokers or patients with diabetes.
- Asymmetry with the other breast — usually managed with a small symmetrising procedure on the other breast if wanted.
- General surgical risks — infection, bleeding, DVT, the risks of a long anaesthetic.
Specific risks and how they apply to you are discussed at consultation, with written information to take home.
What makes a DIEP done well
Two things, consistently, predict a good DIEP outcome:
- Microsurgical volume — the surgeon’s and the hospital’s experience with microsurgery. This is not an operation that benefits from being an occasional add-on.
- Flap-monitoring protocols — specialist post-operative nursing, clear escalation pathways, and willingness to return to theatre quickly if anything changes in the first 24 hours.
Breastory coordinates DIEP reconstructions with GMC-registered consultant plastic surgeons who have subspecialty microsurgical / oncoplastic practice, working in specialist units with established flap-monitoring protocols.