What is a DIEP flap?
A DIEP flap is a type of perforator flap which is based on the Deep Inferior Epigastric Perforator (artery) of groin and includes the skin, subcutaneous tissues of the lower abdomen.
The most commonly used perforator free flap is the DIEP (Deep Inferior Epigastric Perforator) flap. This flap is based on an artery and vein pedicle in the lower abdomen. This perforator free flap has the same skin and subcutaneous tissues as a TRAM flap, but spares the muscle. Thus, the Deep Inferior Epigastric Perforator flap removes no muscle.
It may be used to perform a single, or double breast reconstruction.
Because the muscle is preserved, it is felt that abdominal strength is less affected and the need for mesh to reinforce the abdominal wall repair is not usually necessary.
Because this is a perforator flap, it’s vascular pedicle (blood) consists of the vessels that penetrate or perforate thorough the rectus abdominis muscle and usually splits into two rows of vessels that serve the skin and fatty tissues of the lower abdomen that overly this muscle.
The vessels that make up this vascular pedicle are the deep inferior epigastric artery system which originates from the external iliac vessels in the groin area.
Unlike the TRAM free flap which includes a portion of muscle, the DIEP flap spares the muscle.
The DIEP flap can be used for both immediate and delayed reconstruction for one or both breasts. When it is used for bilateral (both) breasts the flap is dissected so that the pedicle from each groin and its branches are preserved. The skin and subcutaneous tissues of the flap are divided down the middle to create two separate flaps- one for each breast.
Attention is then turned to the chest, where the mastectomy has been performed. Along the side of the breast bone are the internal mammary artery and vein. These are the vessels to which the pedicle vessels of the DIEP flap are connected to immediately restore circulation.
Access to the internal mammary vessels is obtained through the mastectomy wound which may be modified to facilitate the dissection of the vessels as well as for adjustment and tailoring of the flap and chest wall skin to create breast symmetrical to the other.
Often a portion of the second and/or third rib is removed; the internal mammary vessels are dissected free from surrounding tissues and prepared for microvascular repair.
The DIEP flap pedicle vessels are divided close to their origins, and the DIEP flap is brought to the mastectomy site for restoration of its circulation by anastomosis of the pedicle to the internal mammary chest wall vessels.
The vascular repair is carried out with micro sutures and micro couplers under an operating microscope. Once this is done the flap circulation is immediately restored.
The flap is then further tailored, and sutured in place (insetting) to achieve a good symmetrical shape.
At this point the abdomen is closed in the same way as an abdominoplasty.
To improve symmetry further, later surgery is done to tailor the flap and/or to the opposite breast.
Nipple areola reconstruction is done once the breast reconstruction has fully healed and “settled”. For more information on nipple reconstruction.