How a DIEP flap works: Understanding the procedure for breast reconstruction

September 21, 2025 •

4 min read

According to the American Cancer Society, an estimated 287,850 new cases of invasive breast cancer will be diagnosed in 2022 alone, many of which may lead to a mastectomy. For those patients, understanding how a DIEP flap works is crucial, as this advanced procedure offers a natural and long-lasting breast reconstruction option using a patient's own tissue.

Quick Summary

The DIEP flap procedure carefully removes a section of skin, fat, and specific blood vessels from the lower abdomen and transplants this 'flap' to the chest. Using intricate microsurgery, the blood vessels are reconnected, allowing the tissue to thrive and be shaped into a new, living breast, all without sacrificing abdominal muscle strength.

Key Points

Muscle Preservation: Unlike older techniques, the DIEP flap leaves abdominal muscles intact, preserving core strength and speeding up recovery.
Microsurgery is Key: The procedure relies on highly skilled microsurgeons to connect tiny blood vessels from the abdomen to the chest, a crucial step for the flap's survival.
Natural Look and Feel: Reconstructed breasts are made from a patient's own tissue, meaning they look, feel, and age more naturally than implants.
Dual Benefit: Patients receive breast reconstruction and often an aesthetic benefit similar to a tummy tuck from the removal of lower abdominal tissue.
Ideal Candidate Profile: Eligibility depends on sufficient abdominal tissue and overall health, with a comprehensive evaluation needed to determine suitability.
Long-Term Solution: The DIEP flap offers a permanent reconstruction option without the risks or potential for future replacements associated with implants.

What is a DIEP Flap?

The Deep Inferior Epigastric Perforator (DIEP) flap is an advanced, natural tissue breast reconstruction procedure. It uses excess skin, fat, and blood vessels from the lower abdomen—the same tissue that would be removed during a tummy tuck—to rebuild one or both breasts following a mastectomy. The key distinction of the DIEP flap is that it carefully spares the underlying abdominal muscles. Instead, the surgeon works around the muscle, preserving the patient's core strength and function. This innovative approach is a significant evolution from older techniques like the TRAM flap, which required cutting and repositioning abdominal muscles, leading to a more challenging recovery and higher risk of abdominal wall complications.

The Step-by-Step Surgical Process

The DIEP flap procedure is a complex and precise surgery performed by highly specialized microsurgeons. Here is a general overview of the process:

Preparation and Marking: Before the surgery begins, the surgeon marks the planned incision lines on both the abdomen and the chest. A specialized imaging technique, such as a CT angiogram, is used to map the perforator blood vessels in the abdomen to identify the best ones to use.
Flap Harvest: The surgeon makes a horizontal incision across the lower abdomen, similar to a tummy tuck. The selected section of skin, fat, and the specific perforator blood vessels are carefully separated from the abdominal muscle. This step requires immense skill to dissect the vessels without harming the muscle fibers.
Vessel Dissection: With the flap isolated, the surgeon meticulously traces the perforator vessels back to the larger deep inferior epigastric artery and vein, and then severs them. This preserves the blood supply within the flap until it is ready for transfer.
Flap Transfer: The tissue flap is moved from the abdomen to the chest. An incision is made in the chest wall, often along the mastectomy scar. The tiny blood vessels in the flap are then reconnected to blood vessels in the chest using a high-powered microscope and extremely fine sutures. This intricate step, known as microsurgery, is what allows the transplanted tissue to survive and become living, breathing breast tissue.
Breast Shaping and Closure: Once the blood supply is successfully restored and confirmed, the surgeon shapes the tissue into a new breast mound. The abdominal incision is then closed, resulting in a flatter abdominal profile, much like a cosmetic tummy tuck. Drains are typically placed in both the chest and abdominal areas to manage fluid buildup during recovery.

DIEP Flap vs. Other Reconstruction Options

Choosing the right breast reconstruction method is a personal decision based on a patient's medical history, body type, and desired outcome. Here is a comparison of the DIEP flap with other common options:


Feature	DIEP Flap	TRAM Flap	Breast Implants
Tissue Source	Patient's own abdominal skin and fat	Patient's own abdominal skin, fat, and muscle	Saline or silicone implants
Abdominal Muscle	Preserved (no muscle sacrifice)	Sacrificed and transferred with the flap	Preserved (not involved)
Appearance & Feel	Very natural, mimics breast tissue	Can feel firmer due to muscle use	Can look less natural, may feel firm
Longevity	Permanent, ages with patient	Permanent, ages with patient	Requires potential future replacement
Recovery Time	Moderate to long (6-8 weeks typical)	Longer (6-10+ weeks due to muscle harvest)	Shorter (2-4 weeks typical)
Risks	Flap failure (rare), healing issues	Hernia, abdominal weakness, flap failure	Capsular contracture, rupture, infection

The Long-Term Benefits of Choosing a DIEP Flap

Many patients and surgeons consider the DIEP flap the gold standard for natural tissue breast reconstruction due to its numerous long-term advantages. Because the reconstructed breast is made of the patient's own living tissue, it will naturally respond to weight changes and temperature just like natural breast tissue. The muscle-sparing technique protects the abdominal wall from weakness and reduces the risk of hernia, allowing for a better and faster return to full physical activity. Furthermore, there are no concerns about implant rupture, leaking, or the need for future implant replacements.

Candidate Eligibility for the Procedure

While the DIEP flap is an excellent option, it is not suitable for everyone. Good candidates typically have a sufficient amount of excess fat and skin in their lower abdomen to create a new breast. Previous abdominal surgery may impact eligibility, especially if the blood vessels were compromised. Health factors like smoking, diabetes, and certain cardiovascular conditions can also affect whether a patient is a suitable candidate. A plastic surgeon specializing in microsurgery will thoroughly evaluate each patient's medical history and body type to determine the best course of action.

The Recovery Process

Recovery from a DIEP flap is a significant undertaking, but the long-term benefits are often worth the commitment. Most patients can expect a hospital stay of 3 to 5 days, during which the surgical team closely monitors the blood flow to the new breast tissue. Drains will remain in place for one to three weeks. Light walking is encouraged soon after surgery to aid circulation, but strenuous activity and heavy lifting are restricted for up to six weeks. It can take several months to feel completely back to normal, but with careful adherence to recovery instructions, a successful outcome is highly likely.

For more detailed information on reconstructive breast surgery, you can find authoritative resources from leading medical institutions. For example, Johns Hopkins Medicine provides comprehensive guides and expert insights on breast reconstruction techniques.

Conclusion

The DIEP flap procedure is a remarkable advancement in reconstructive surgery, offering a durable, natural, and aesthetically pleasing solution for breast reconstruction. By leveraging a patient's own tissue and preserving vital abdominal muscles, it provides a functional and long-lasting result. This complex microsurgical procedure is a testament to modern medicine's ability to restore a sense of wholeness and confidence for women recovering from a mastectomy.

Frequently Asked Questions

Generally, patients report less post-operative pain with a DIEP flap compared to a TRAM flap. Because the DIEP flap preserves the abdominal muscles, patients avoid the significant discomfort and muscle weakness associated with the muscle-sacrificing TRAM procedure.

The duration of a DIEP flap procedure can vary, but it typically takes several hours, often between four and eight hours. The time can be longer for a bilateral reconstruction (both breasts).

Yes, a DIEP flap can be performed immediately following a mastectomy, which is known as immediate reconstruction. It can also be performed later, in a delayed reconstruction, if chemotherapy or radiation is necessary.

Flap failure is a rare but serious complication, often due to blood supply issues. Surgeons monitor the flap closely after surgery. If blood flow is compromised, a return to the operating room may be necessary to correct the problem. In some cases, if the flap cannot be salvaged, alternative reconstruction methods may be considered.

No, a DIEP flap uses a patient's own tissue, eliminating the need for implants. However, in some 'hybrid' cases, an implant may be used in combination with a DIEP flap to achieve a specific size or shape, though this is less common.

Initially, the reconstructed breast will have no sensation. Over time, some patients experience a return of nerve sensation, but it is rarely complete. Nerves grow very slowly, so any return of feeling can take many months or even years.

Most people need approximately six to eight weeks to recover, though the hospital stay is usually 3-5 days. Full recovery and a return to all normal activities can take several months.

Due to federal laws like the Women's Health and Cancer Rights Act (WHCRA), most insurance plans that cover mastectomy must also cover breast reconstruction, including DIEP flap surgery. However, coverage can vary, so it's important to verify with your specific provider.