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Are You A DIEP Flap Candidate?

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

The most common areas of confusion 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.
So which previous surgeries DO cause a problem?
1) 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 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. I do not share this opinion.
Most of the time this advice 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 exceptionally rare for us to find these blood vessels are damaged and cannot be used.
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 outweigh the benefits - At PRMA we set an upper BMI limit of 40 as we have found that performing the procedure on women with BMIs greater than this significantly increases the rates of complications (especially wound healing problems).
Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques . He and his partners are in-network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!


Dear Dr Chrysopoulo, my name is Alexandra Voudouri and I am writing to you as my sister Niki (39 mother of two) is a BRCA2 carrier and wants to have a BPM and a DIEP flap reconstruction - if possible - at the same time. Could you tell me how long it would take, if this double surgery is provided at PRMA and how much it will cost, as my sister lives in Athens Greece and we will have to cover the costs privately? Further do you know perhaps any plastic surgeon in Greece who is experienced enough in such microsurgical procedures and whom you would recommend? Thank you in advance Alexandra Voudouri
Hi Alexandra - great questions! Yes, we can definitely do the mastectomy and reconstruction at the same time. The surgery is about 8 hours long and cost varies depending on each individual patient and what they need. If you'd like to have your sister complete our virtual consultation form to see what kind of reconstruction she is a candidate for, you can find that form via this link --> Unfortunately I'm not aware of surgeons in Greece that perform the DIEP flap surgery. We do however, see patients from across the country and can also help you get hotel and travel assistance if you qualify. Let me know if you have any other questions. -Brandy

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