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

Have a question about breast reconstruction you’d like answered from our surgical team? Just ask us!

Is It Normal to Suffer With Abdominal Hernias After Reconstruction Surgery?

The below question is answered by Richard M. Kline Jr., M.D., of The Center for Natural Breast Reconstruction.

Is it routine to suffer with abdominal hernias after reconstruction surgery? Is it possible to correct this so there will be no more hernias or surgeries?

Sorry to hear about your problem.

It’s certainly NOT routine, at least not with experienced surgeons doing muscle sparing reconstruction (such as the DIEP flap). Unfortunately, however, it can occasionally happen under the best of circumstances, and we always warn patients about this risk, although I haven’t had a patient with a hernia in several years. Depending on the particular circumstances, it should almost always be possible to fix it, although in the worst cases it could require the implantation of permanent plastic mesh. A worst-case scenario would be a patient who is significantly overweight, with a large volume of intra-abdominal fat, which would push heavily against the muscular abdominal wall from the inside. However, even this situation should be correctable. If your plastic surgeon isn’t comfortable fixing it, then a general surgeon may be (although general surgeons typically refer the WORST hernias to plastic surgeons).

Good luck, and please feel free to ask more questions if you need more information.

—Dr. Richard M. Kline, Jr.

Does Radiation Affect My Options For Breast Reconstruction?

Dr. James Craigie

Dr. James Craigie

The question below is answered by Dr. James Craigie of The Center for Natural Breast Reconstruction.

I am not sure if I will need radiation after my mastectomy. What factors should I consider before going ahead with breast reconstruction?

Radiation therapy is part of the treatment for breast cancer for some but not all patients. To determine if it is necessary for any individual, the details of the cancer or the final path results must be known. The most common situation for radiation after mastectomy is based on the size of the cancer and the number of positive lymph nodes.

When a patient would benefit from radiation the treatment may affect the options for breast reconstruction as well as the timing of the reconstruction. There are several advantages to starting the breast reconstruction at the time of the mastectomy. These include: the breast surgeon can save more of the breast skin or even the nipple and this can set the stage for the best possible result, and avoiding an extra step and an extra recovery period.

If radiation will definitely be needed after mastectomy then I do not recommend immediate natural breast reconstruction because the radiation can possibly damage the new breast. In this situation the reconstruction would start approximately 6 months following radiation. These decisions are best made following the advice of your oncologist, breast surgeon, and plastic surgeon all working together. For this reason I am a strong advocate of the multi-specialty breast conference where each patient can be presented to all the specialists at once so they can share their opinions right away. Cooperation between experts can ensure better results and more options for each patient.

It is important to remember that if you need radiation for the treatment of breast cancer it does not mean you cannot have a very good result with natural breast reconstruction. It may however determine the order and timing of when the breast reconstruction should begin.

—James E. Craigie, MD


Is a DIEP Flap Reconstruction Right for You?


The below question is answered by Dr. Richard M. Kline, Jr., of The Center for Natural Breast Reconstruction.

My plastic surgeon told me that I did not have enough excess tissue in my abdomen to have a DIEP. What can I do now?

That’s a common question, thanks for asking. Many women wonder themselves if they actually have enough tissue for DIEP flap reconstruction, and others are told by their plastic surgeon that they do not. When assessing whether or not a patient’s abdomen can meet their reconstructive needs, several factors need to be taken into account.

First, are we talking about reconstructing one breast, or both breasts? Obviously, reconstructing both breasts takes twice as much tissue as reconstructing one breast. When only one breast is needed, it is possible to use both sides of the abdomen to reconstruct just one breast. This is called a “stacked flap,” which utilizes both sides of the abdomen, with two separate blood supplies, to make just one breast. We routinely do this procedure for patients who just need one breast reconstruction, but require both sides of their abdomen to get the size breast that they desire. It’s more complicated than connecting just one blood supply, but our practice has performed this operation well over a hundred times, with excellent success. In fact, we believe that stacked flaps may be less susceptible to fat necrosis (a complication of DIEP flaps where some of the fat, usually on the edge, dies and gets hard) than ordinary DIEP flaps.

Second, in trying to answer this question, the patient’s desired breast size must be taken into account. A patient who wants both breasts reconstructed to size “D,” but who does not have enough abdominal tissue to make a” D” size breast on each side, might have adequate tissue to make a “B” sized breast on each side. In this situation, if “B” sized breasts would not be acceptable to the patient, then we would usually recommend using the buttocks (a GAP flap) as the donor site.

Use of the buttocks for breast reconstruction, particularly for reconstructing both breasts at the same surgery, is significantly more complicated than using the DIEP flap. Fortunately, we have extensive experience with this procedure, having performed it several hundred times with a 99% success rate. If a patient did not wish to use their buttocks as the donor site, then they would still have the option of accepting a smaller breast size from the abdomen, or they may possibly decide to use implants, foregoing autologous reconstruction altogether.

Finally, for the patient who is told by their surgeon that they do not have enough tissue for a DIEP flap, it is worth noting that it can be extremely difficult for a surgeon who does not routinely perform DIEP flaps to properly assess the amount of donor tissue a patient has available in her abdomen. The thickness of the subcutaneous fat, which is the thickness that can be “pinched” between the skin and the muscle of the abdominal wall, is of paramount importance in assessing how large a breast can be made from the DIEP flap.

In addition, the maximum height of the flap also plays a role in determining what size breast can be made. In assessing how “high” a flap can be safely harvested from the abdomen, it is important to look at how much loose skin is present between the belly button and the bottom of the ribs.  If there is a lot of loose skin in this area, then it will stretch downward more easily to close the lower abdominal wound after harvest of the flap, thus allowing for a larger flap to be obtained. Again, precise assessment of the availability of abdominal donor tissue requires a significant amount of experience on the part of the surgeon, and is ideally performed while examining the patient in person, as opposed to simply looking at photographs.

In closing, to determine if a patient has “enough tissue for a DIEP flap,” we must ask these questions:

  • Are we reconstructing one or both breasts?
  • What size breast are we attempting to reconstruct?
  • What is an experienced surgeon’s assessment of how much tissue can be removed from the abdomen?

Only by taking all of the above into account can a meaningful answer to the question be obtained. We believe that effective communication between the patient and the reconstructive team, in this situation and in most others, is often the key to a successful and happy outcome.

—Richard M. Kline, Jr., M.D.