DIEP Flap Surgery Best for Natural Breast Reconstruction Results?

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:

Typically able to use more of the abdominal tissue to reconstruct the breast because the microsurgical options typically provide a better blood supply.
Eliminates the abdominal bulge sometimes present when you turn the TRAM flap (the bulge is created by the attached rectus muscle).
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.

There are pros and cons for everything we do. Using your own tissue(DIEP breast reconstruction) has benefits such as:
No implant complications/revisions, Tummy tuck, Replaces breasts with similar tissue of fat, Softer and more natural result if you have to have radiation
The cons:
Longer surgery, Longer recovery(due to multiple incisions)
The caveat to this is that you have to be a good candidate for DIEP reconstruction. See a board certified plastic surgeon to help evaluate this!

DIEP surgery uses excess lower abdominal skin and fat to replace a breast removed through mastectomy with soft, warm tissue from your own body.  This surgery is very complicated and requires a skilled and experienced surgeon at a center that also performs these surgeries frequently.  Despite the complexity of the procedure, the vast majority of the time it is successful and results in a breast that feels and looks very natural.  After reconstruction is complete, your breast will continue to change with you over time, mimicing the changes of a natural breast with changes in weight and with time.

I work in Oakville, Canada.  Everything related to breast cancer reconstruction is covered by OHIP.  I have a strong bias towards DIEP flaps.  No doubt it is a longer surgery and has potential complications.  But most of the time it works out really well.  You can get excellent results with implants and autologous tissue (using your own body).  However, more times than not the result is more natural using your own body.  Talk to your surgeon to see if you are a candidate.

The diep flap reconstruction is generally covered by insurance as almost all insurance covers breast reconstruction.  The total cost of the surgery and the total out of pocket expenses varies by state and by insurance policy contract.

When done properly, the DIEP flap can give a very natural look for your breast reconstruction.  The surgery uses your own tissue and ages with you over time.  If you gain weight, they get bigger; if you lose weight they get smaller.  With successful surgery, you will not have to ever worry about getting an implant changed.

See a skilled plastic surgeon in your area who has extensive experience performing DIEP flap surgery. I am in Nashville, TN and have a greater than 99% success rate with the DIEP flap.

With the advent of microsurgical perforator flaps, this form of reconstruction has revolutionized plastic surgery. Along with them, the application in breast reconstruction has been tremendous. By the replacement of the skin and soft tissue that is removed during the mastectomy with viable, well-vascularized, excess skin and soft tissue from the lower abdomen, a beautiful breast reconstruction may be achieved that is completely your own tissue. This Deep Inferior Epigastric Perforator (DIEP) flap has gained much notoriety for breast reconstruction today.

The tissue is taken from the lower abdomen, much like that removed during a tummy tuck. Utilizing the excess tissue from this area and hiding the incision low on the abdomen, well-hidden within the panty line, the donor site is an excellent option for borrowing tissue for a breast reconstruction. This skin, fat, and soft tissue, along with its blood supply is taken and moved into the breast area. These small blood vessels are then reattached via assistance of a microscope to vessels in the breast area. This tissue is then shaped and molded to reconstruct an aesthetically pleasing breast reconstruction.

With this new advent of perforator flap techniques, it is the most innovative and state-of-the-art technique used today in breast reconstruction, let alone plastic surgery as a whole. Unlike the traditional way of reconstructing a breast utilizing this tissue (aka TRAM flap), the DIEP spares the muscle of the abdominal wall, by carefully dissecting the blood vessel from within the abdominal musculature and leaving the muscle in place. This muscle-sparing, perforator flap type of reconstruction is beneficial for these reasons. There is less donor site morbidity from the abdomen, since the muscle is left intact. Along with that, there is less postoperative pain. The function of the muscle remains, so abdominal wall integrity remains intact and there is less chance of hernias or bulges, since the muscle remains. These problems are much increased with the conventional TRAM flap, but unlike it, the aforementioned benefits are obtained with the DIEP microsurgical free tissue transfer breast reconstruction.
Unlike conventional TRAM flap reconstructions, use of our refined perforator flap techniques allow for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast the contour of the abdomen is often improved much like a tummy tuck. This well-vascularized flap reconstruction also is also completely your own tissue, and often resembles, moves, looks, and feels more like a natural breast than reconstructions using implants. Other perforator flaps used for breast reconstruction include the SIEA (Superficial Inferior Epigastric Artery), SGAP (Superficial Gluteal Artery Perforator), IGAP (Inferior Gluteal Artery Perforator), and TAP (Thoracodorsal Artery Perforator) flaps, among others.

If you're interested in an advanced reconstructive procedure as such, very few surgeons have been trained to perform these and even fewer offer these procedures due to its complexity and skill involved. It may be difficult to find an experienced surgeon to perform this type of surgery with many patients, unfortunately, having to travel away to obtain such reconstruction.

There is no one best form of breast reconstruction for all patients. Although a DIEP flap can be a wonderful reconstruction option, it is suited primarily to patients with an adequate amount of lower abdominal skin and fat. In addition, if a patient may have radiation therapy after mastectomy-- which is sometimes only determined after the mastectomy-- then I do not usually recommend a DIEP flap, because the radiation can damage the flap.
If I believe the patient is at significant risk of needing radiation postoperatively, I will usually place a tissue expander at the time of mastectomy. After chemotherapy and radiation, I can remove the tissue expander and use a DIEP flap or other autogenous tissue to reconstruct the breast.

\Plastic surgeons have devoted countless hours in honing new and better techniques to reconstruct the breast to make a woman feel whole again, fulfilling the need for form and function.   There are several ways to recreate the breast. There is Implant Reconstruction and Autologous Tissue (your own body tissues) Reconstruction. There are advantages and disadvantages with either technique; however, I believe that using your own tissues without an implant creates the most natural, soft, living breast. In the past, the TRAM (Tranverse Rectus Abdominus Muscle) flap technique was widely used to recreate the breast. This required taking the abdominal skin, fat, and muscle to reconstruct the breast. Today’s physically active women demand that the abdominal muscles be preserved.  

     High tech breast reconstruction with the DIEP flap has evolved now to the point where we can take the same “tummy tuck” tissue and "transplant" it while preserving the abdominal muscles. This requires the skills of microsurgery which allows us to move those tissues and reconnect their blood vessels with very fine sutures and instruments. Microsurgical Breast Reconstruction is a technique that has become available only more recently with a limited number of plastic surgeons in the country who have dedicated their skills to operating under the microscope. Because of this, not many patients know about these new and cutting edge techniques also known as the DIEP, SIEA, GAP, and TUG flaps.

      I recommend that you identify microsurgergical centers of excellence in your local area and have a detailed discussion with your plastic surgeon about whether you are a good candidate for this operation.  We perform 2-3 microsurgical free flaps per week with a >99% success rate.   Plan for an inpatient stay of 4-7 days, and future surgeries for touchup and nipple reconstruction.  

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 my opinion the goal of all breast surgery is a natural result. Traditionally, breast reconstruction differs from aesthetic breast enhancement because the goal is a natural result in clothing only with breast reconstruction. In my hands I can achieve a natural result close to aesthetic enhancement with tissue expanders and implants.
This does not mean an "natural" result can not be achieve with flaps (DIEP, TRAM, etc) especially the hands of a surgeon that performs these types of reconstructions routinely. Any procedure for reconstruction no matter the level of sophistication can produce undesirable results. The result depends on the SURGEON and not the PROCEDURE.