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Are You A DIEP Flap Candidate?

By Dr Chysopoulo

The DIEP flap procedure has rapidly become the "gold standard" in breast reconstruction. While not every woman is a DIEP flap candidate, many are turned away when in fact they needn't be.

Typical misconceptions include:

1. Previous Abdominal Surgery - While some types of previous abdominal surgery can make the DIEP flap procedure impossible to perform, most of the time previous abdominal surgery really isn't an issue. Many women these days have had a previous c-section or hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery, but this is rare. A previous c-section, hysterectomy, or tubal ligation is not a contra-indication to having the procedure. If your surgeon is worried about potential damage from previous surgery then certain tests can be performed to examine the anatomy more closely. This can include a simple doppler ultrasound exam in the office or a more involved test like a CT angiogram.

Women that have had a previous TRAM flap, tummy tuck or very extensive abdominal wall surgeries (like complex repairs of huge hernias) cannot have a DIEP or SIEA flap reconstruction because the lower tummy tissue that is needed has already been removed, disconnected or moved around.

While most previous abdominal surgeries may not prevent DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and even hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery.

2. An umbilical hernia - It is very unlikely that an umbilical hernia would prevent DIEP flap surgery. Most umbilical hernias are small. A very large umbilical hernia can make the surgery harder but even this is not usually a contra-indication to having the procedure.

3. Previous Chest Radiation - One of the most important things for the reconstructive surgeon to achieve is to replace the damaged, firm irradiated tissue with normal, healthy, soft tissue. If the irradiated tissue is not healthy enough to be used as part of the reconstruction (as is the case in many instances), it will be removed and replaced by the healthy (DIEP) tissue.

I have visited with a fair number of patients who have previously been told they are not candidates for DIEP flap reconstruction because they received chest radiation after their mastectomy. That's not the case. Healthy tissue (like a diep flap) is by far the best reconstructive option after radiation.

Most of the time this misconception seems to stem from fear that the radiation may have caused damage to the internal mammary vessels in the chest. These are the blood vessels that are usually used to connect the DIEP flap to the chest. In reality it is very rare for us to find these blood vessels are damaged to the point they cannot be used. In instances where the internal mammary blood vessels cannot be used for whatever reason, other blood vessels can be used instead (eg internal mammary perforators or thoracodorsal vessels).

4. Not the Right Amount of Tissue - You don't need to be overweight to be a candidate for a DIEP flap. What matters is the distribution of the fat. We have performed DIEP flaps on smaller breast, thin women with a BMI (body mass index) of 20 (and even less) because the fat that they did have was "in all the right places". Having said that, there is an upper limit beyond which the risks of surgery typically outweigh the benefits - At PRMA we set an upper BMI limit of 40 as we have found that performing the procedure on women with a BMI greater than this significantly increases the rates of complications (especially wound healing problems).

Hope this info helps!


Dr. C, I wish all women considering DIEPFlap surgery could have this valuable information. Because I had a double whammy: 1. Delayed DIEP (7 months after my double mastectomy) & 2. A left breast that was radiated 12 yrs. prior to my DIEPFLAP my damaged, radiated skin that included scar tissue was replaced by healthy tissue. Women need to know it is possible and the inquiry is definitely worth it to see if they are a candidate. Additionally, I'd like to say that I am grateful I found a world class, skilled surgeon to perform my DIEPFlap surgery and that surgeon was you!! Thank you for your dedication, passion and always doing what you can to inform women about this life-changing surgery. ~ Terri
Our pleasure Terri! Honored to play a part! Thank you so much for all you do to help others through your patient advocacy and!
I will soon be having a bi-lateral mastectomy for breast cancer and was wondering if I would be a candidate for DIEP flap reconstruction. Two years ago I had abdominal surgery for LG-ESS and radiation to the abdominal area. I also have an umbilical hernia about 6cm. Would this radiation treatment prevent DIEP flap as an option for reconstruction?
Hey Cheryl! It is hard to say without a physical examination by a board-certified plastic surgeon who performs the DIEP flap. I would recommend consulting with someone before your mastectomy if possible. If you are not a DIEP flap candidate, there are other tissue flap options such at the TUG or the GAP flap you may be interested it. Please reach out with any questions!
Spot on with this write-up, I absolutely feel this website needs a great deal more attention. I'll probably be back again to see more, thanks for the information!

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