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Stacked DIEP Flap

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The photographs included on this page are the results of reconstructive procedures performed by the surgeons at the Center for Restorative Breast Surgery.

Stacked DIEP flap reconstruction is a newer approach to DIEP that can be used to reconstruct one breast in women who don’t have a lot of extra belly tissue and therefore aren’t eligible for standard DIEP surgery.

DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. In a standard DIEP flap reconstruction, fat, skin, and blood vessels are cut from the wall of the lower belly and moved up to your chest to rebuild your breast(s). Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. DIEP is often referred to as a muscle-sparing or muscle-preserving type of flap, which means that no muscle should be removed or cut. Because of this, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to any of the TRAM flap procedures, which do involve cutting the muscle tissue either partially (muscle-sparing TRAM) or completely (conventional TRAM).

Some women don’t have enough belly tissue to be good candidates for DIEP reconstruction. Typically they’ve had to use either an implant or tissue from other sources, such as the hip or thighs, to reconstruct the breasts. If you’re in this group, you would need to do this if you’re having both breasts reconstructed. However, the stacked DIEP flap may be an option for you if only one breast is being reconstructed. In this approach, the plastic surgeon takes the entire flap of tissue from the lower abdomen (one continuous piece), or one flap from each side (two pieces), and uses the tissue to reconstruct the single breast. The surgeon can either “stack” the flaps, or fold the intact flap in half, to create the new breast. Stacking the flaps in this way often can provide the volume that is needed.

stacked diep flap
Stacked DIEP Flap Reconstruction -- Before and After

Because the stacked DIEP flap procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer it and it's not available at all hospitals. Stacked DIEP reconstruction is even newer than the standard DIEP procedure, so this can add to the difficulty of finding an experienced surgeon. If you're considering a stacked DIEP flap, you may have to research the surgeons and facilities that offer what you want. Your doctor may be able to refer you to plastic surgeons who can offer stacked DIEP flap reconstruction.

Because skin, fat, and blood vessels are moved from the belly to the chest, having a stacked DIEP flap means your belly will be flatter and tighter -- as if you had a tummy tuck. Still, a stacked DIEP flap does leave a long horizontal scar -- from hipbone to hipbone -- about one-third of the way between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, the abdomen is closed. No mesh material is required to support the abdominal wall as may be the case with a TRAM flap. Your navel is then brought back out through a separate incision and reshaped.

If you’re thinking about prophylactic removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. Again, the stacked DIEP flap procedure can only be used for unilateral (one-sided) breast reconstruction. If you’re having both breasts reconstructed, you need to consider other sources for the tissue flaps, such as your buttocks, thighs, or back. Or you can have reconstruction with implants.

A stacked DIEP flap is also not a good choice for:

  • Women who already have had certain abdominal surgeries, including colostomy (surgery that attaches the large intestine to an opening in the abdominal wall) or abdominoplasty (tummy tuck). This does not include midline incisions extending from the belly button to the pubic region or other routine abdominal operations. If you have had a C-section, hysterectomy, gall bladder surgery, appendectomy, or tubal ligation, etc., you may still be a candidate for a stacked DIEP flap.
  • Women whose abdominal blood vessels are small or not in the best location to do a stacked DIEP flap. (A new approach called the APEX FlapCM may be useful in this situation, but availability is very limited.)

Learn more about DIEP flap reconstruction on these pages:

The photographs on this page are copyrighted materials and no reproduction or use of these photographs is permitted except with the written consent of the Center for Restorative Breast Surgery.


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