DIEP Flap Surgery Best for Natural Breast Reconstruction Results?

A DIEP flap stands for Deep Inferior Epigastric Perforator flap. It is an evolution in technique from a traditional free TRAM flap. The main difference is the goal of sparing the muscle from the abdomen to decrease the likelihood of bulging or hernia in the abdomen after the procedure.

DIEP flaps for breast reconstruction are typically covered by your insurance provider. The cost issue arises when a surgeon does not participate with your insurance provider. The higher cost is due to the time and risk of the procedure, not based on the "naturalness" of the reconstruction.

In general, breast reconstruction is a trade-off. Implant reconstruction can have a very natural appearance in the right patient. However, it often requires multiple (though shorter) procedures and the implants themselves may need replacement over your lifespan. Using your own tissue (autologous procedures) via a TRAM flap, DIEP flap, or other tissue provides a reconstruction which is made up of skin and fat that feels more natural. However, the trade off is the longer operation, the risks of complications in the abdomen, and in the case of a free flap (such as a DIEP) the risk that the part or all of the flap may not live.

Breast reconstruction requires a long consultation to properly educate you on your options. I recommend a thorough consultation with your plastic surgeon to review all of your options and to show you photos of the different types of reconstruction available to you.

First, breast reconstruction after mastectomy must be covered by your insurance thanks to a 1998 federal law. This is one procedure insurance companies can't successfully deny. So given the question regarding cost -- this should not be a self-pay cosmetic procedure.

Now to address your question regarding the DIEP flap. The DIEP flap utilizes the excess skin and fat that is normally thrown away in a cosmetic tummy tuck. It is like its predecessor, the TRAM flap that harvested the excess skin, fat, and muscle from the belly. However, unlike the TRAM flap, the DIEP flap specially harvests the skin and fat and spares the abdominal wall muscles. the DIEP flap is an advanced microsurgical tissue transplantation procedure.

Autologous reconstruction such as the DIEP or TRAM flaps generally can be performed without the need of a foreign body implant. Once your DIEP flap has been performed (generally > 98percent success rate), your reconstructed breast is yours to keep. It is your own tissue. There are no risks for foreign body scar tissue formation or implant failure. However, autologous reconstruction requires an incision somewhere else on your body and is more involved in terms of operative time and recovery.

There is no one perfect answer for the "best" reconstruction. It's what is right for your and your own individual goals.

In my San Francisco area practice I have been able to offer my patients a wide range of reconstructive options. I've had the opportunity to co-found a breast reconstruction program and found two microsurgical programs which primarily have focused on breast reconstruction.

The two basic categories of breast reconstruction include implant reconstruction (typically tissue expander followed by a permanent implant) and autologous tissue (using your own body's tissue to reconstruct your breast).

I believe that if you are going to use autologous tissue a DIEP flap (or a muscle sparing free TRAM where some of the rectus muscle is taken) gives superior results to a tradition TRAM (where the abdominal tissue is based on the rectus muscle and remains attached).

Specific benefts of a free TRAM or DIEP operation vs. a pedicled TRAM include:

1. Typically able to use more of the abdominal tissue to reconstruct the breast because the microsurgical options typically provide a better blood supply.
2. Eliminates the abdominal bulge sometimes present when you turn the TRAM flap (the bulge is created by the attached rectus muscle).
3. Better abdominal wall strength with decreased risk of hernia (this is because the TRAM flap sacrifices the entire rectus muscle whereas the DIEP and muscle sparing free TRAM leave the bulk of that muscle intact and functional.

With regard to cost - microsurgical breast reconstruction is a much larger operation. It typically takes me 2-3 hours to perform a pedicled TRAM breast reconstruction. A microsurgical breast reconstruction (DIEP, SIEA, free TRAM, SGAP) typically takes 5-6 hours.

In addition - patient's need a significantly longer recovery time from a microsurgical breast reconstruction and my patient's (and this is typical) stay in the intensive care unit for several days for close monitoring of the microsurgical areterial and venous connections.

While autologous tissue breast reconstructions are significantly more laborious and require greater time to recovery (microsurgical or not), most experts agree that an implant breast reconstruction looks best at about 6 - 24 months after surgery and begins to look worse overtime whereas autologous tissue reconstructions look reasonable about 6 months post-op and improve over the next year and are incredibly lasting in terms of natural appearance.

In addition, using your own tissue has the benefit of being resistant to infection, capsular contracture, implant rupture, etc.

The bottom line is you need individualized review of your options and it should come from a board certified plastic surgeon who performs ALL types of reconstruction - so you get a non-biased answer.

Interestingly, in terms of numbers, if you look at all comers most people get breast implant reconstructions likely because many surgeons don't perform microsurgical breast reconstruction and because insurance compensation is better for implant reconstruction (in terms of compensation vs. amount of work - no one would argue that implant reconstruction is more laborious than microsurgical breast reconstruction). If you isolate cost as a factor (ie look at university programs or centers of excellence where insurance compensation may not be as large a factor) many more people get autologous breast reconstruction, likely because of the superior results.

Please do not hesitate to contact my office if you have additional questions regarding breast reconstruction.

You are absolutely right that a DIEP flap produces the closest tissue match to native breast tissue.  Breast tissue primarily consists of skin and fat, as does the DIEP flap.   

As far as cost, breast cancer reconstruction is covered by law under health insurance.  So please do not base your surgical decision on cost.  Most breast reconstruction surgeons can work with your insurance company to obtain coverage.

The primary benefit of the DIEP flap are the "Added Benefits".   Abdominal musculature and fascia are preserved, which allows maintenance of abdominal core strength and function.   In comparison to the TRAM flap (rectus muscle removed), the rate of hernia formation is almost negligible with a DIEP flap.

If you are considering a DIEP flap, I highly recommend that you find a Board Certified Plastic Surgeon with a practice focus and extensive experience in the DIEP flap technique.   

DIEP Flaps are when ONLY skin and fat from your lower abdomen are used to reconstruct your breast. No muscle is taken like in the TRAM operation. By avoiding taking muscles, you preserve your core strength. DIEP flaps should be performed by surgeons experience in microsurgical breast reconstruction. DIEP flap breast reconstruction do create natural breasts. The other advantages of DIEP flap breast reconstruction are that the flap will not rupture like implants and will change with you over time. 

In general, using your own tissue makes for a more natural looking and feeling breast but at the expense of more scars and a much longer recovery than from implant reconstructions. This is especially true in radiated patients and in one sided reconstructions. Bilateral reconstructions without radiation can be performed adequately with implants.

The DIEP flap and the free TRAM flap are probably the "Cadilacs" of breast reconstruction both using the skin and fat of the lower abdomen that would be disposed in a tummy tuck to make the breast.

I personally favor the free TRAM because it has a stronger blood flow than the DIEP flap and minimal difference in functional abdominal compromise. Also, you only get to do these operations ONCE so if you do the DIEP and it fails, you can't go back and do a free TRAM later.

A free flap breast reconstruction is more expensive than a pedicled TRAM or tissue expander- implant recosntruction. Some surgeons charge more for a perforator flap reconstruction than a free-Tram. I prefere autologous tissue reconstruction over a tissue expander and implant. I think it gives a more natural appearance and feel.

The DIEP flap procedure can reconstruct a breast that is softer, more naturally shaped, and more lasting than using a breast implant or other flap procedures for breast reconstruction.  Yes, the DIEP flap surgery is longer and has a longer recovery period than breast reconstruction using implants, and that is why it costs more.  However, breast reconstruction after mastectomy surgery is considered an important part of treatment for breast cancer and is generally covered by health insurance, as stipulated in the Womens' Health and Cancer Rights Act of 1998.  Studies show that 10 or 20 years after breast reconstruction, women who have had DIEP flap breast reconstruction are more satisfied than women who had reconstruction with breast implants.