DIEP Flap Procedures: Can You Restore My Original Breast Size? Do You Remove Muscle?

This week, Dr. Richard Kline of The Center for Natural Breast Reconstruction answers your questions.

Q: I am having a double mastectomy on August 1st. I want to have a DIEP flap reconstruction, but will have to settle on being half the size I am now because there isn’t an abundance of fatty tissue in my tummy. I am a full C cup now and will probably be a B cup following the reconstruction. Can additional fat be harvested from my buttocks at the time of my initial surgery to make me look like I do now or do I have to wait until Stage 2?

A: There are a few potential ways to look at your situation.

First, it is possible to do DIEPs and GAPs simultaneously (4 separate flaps). We don’t do this, because we have concerns about our ability to monitor the buried flap, but we do know have references to associates who can and we are happy to provide you with this information.

Second, it is possible to inject fat into the DIEP flap, and potentially the mastectomy skin flaps as well (if they are thick enough), as well as in the pectoralis muscle at the time of the DIEP flap. All that together will buy you some extra size, but it’s hard to predict how much.

Finally, you could do fat injections after healing in a subsequent stage(s). I would call this the “tried-and-true” technique, little to lose, much to potentially gain. We are investigating BRAVA as an adjunct to this, but not quite ready to use it yet.


Q: What happens if I am getting a DIEP flap done and some muscle has to be removed from my abdominal area?

A: A true DIEP flap never results in the removal of muscle, by definition. Some flap surgeons apparently tell patients they may need to remove a little bit of muscle, and we’re not sure why they say that, because we’ve never found it necessary in many hundreds of flaps.

However, with rare exceptions, the rectus muscle does have to be “disassembled” (and put back together again, of course) to remove the blood vessels, and this can occasionally result in partial loss of muscle function. We work extremely hard in designing each DIEP flap to maximize the blood supply to the flap, while minimizing the potential for loss of muscle function.

We obtain an MR angiogram pre-operation. This  requires an unusually strong 3T MRI for best images, which gives us an excellent “road map” of your individual perforator anatomy. We also frequently use the SPY intraoperative laser fluorescent angiogram to help determine exactly which perforating vessels supply the flap best. Thanks to these technologies, in addition to using the best surgical technique we can, it has been many years since we have encountered any significant functional abdominal wall problems in any of our patients.

Hope this helps!

Dr. Richard M. Kline

Center for Natural Breast Reconstruction

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