المتخصصون في المجالات الطبية

April 28, 2026

Deep inferior epigastric perforator (DIEP) flap surgery has been the leading autologous breast reconstruction procedure for decades. It is an important option for patients requiring mastectomy either for breast cancer treatment or prophylaxis.

A DIEP flap is a section of skin and fat in the abdomen that is transferred with its blood supply to rebuild the breast mound. Blood vessels in the flap are connected to those in the chest to provide blood flow to the reconstructed breast.

Both implant-based and autologous approaches can achieve soft, aesthetically pleasing results. A key advantage of autologous reconstruction is its durability. Once the reconstruction process is complete, there is no need for routine replacement or future device-related surgery. By contrast, implants are medical devices that generally require removal or exchange at some point over a patient's lifetime.

The plastic surgery team at Mayo Clinic in Rochester, Minnesota, performs a high volume of these procedures each year. Their experience with both routine and complex surgeries helps enhance care. Here, plastic surgeons Christin A. Harless, M.D., and Aparna Vijayasekaran, M.B.B.S., describe nine strategies their team uses to enhance the patient experience and outcomes.

1. Deciding when to do breast reconstruction

Whether to offer DIEP flap surgery at the time of mastectomy or afterward is a common question. However, immediate DIEP flap reconstruction is available at only a limited number of centers nationwide, including Mayo Clinic. Combining the mastectomy and DIEP reconstruction in one surgery can be very safe and a good option for some patients. This decision is based on the indication for the mastectomy.

If the patient is likely to need additional adjunct therapies, especially radiation therapy, which can cause distortion of the DIEP flap or loss of volume, the preference is to first perform the mastectomy with immediate tissue expander placement. This step allows the pathology to be finalized and the multidisciplinary team to make subsequent recommendations regarding additional treatment prior to the more involved DIEP breast reconstruction.

"Most of the immediate DIEP flap reconstruction procedures we do are for patients who have a mastectomy for prophylactic reasons," Dr. Harless says. "Combined surgery may also be possible for some patients with early breast cancer who are unlikely to need radiation therapy."

For more-advanced cancers, surgeons typically recommend performing mastectomy and DIEP flap reconstruction as separate procedures. This approach allows time for radiation therapy between surgeries if needed.

2. Helping patients choose the right type of breast reconstruction

Breast reconstruction after mastectomy is not for everyone. For patients who are not sure or are considering reconstruction, having a conversation with a plastic surgeon before the mastectomy is important.

"If patients decide they want breast reconstruction, we'll recommend a skin- or nipple-sparing mastectomy and provide a roadmap for their reconstruction to help achieve their goals," Dr. Vijayasekaran says. "By preserving the patient's breast skin, we're able to create a more natural-appearing breast shape with fewer surgical procedures and fewer scars."

Patients must also choose between implant-based and autologous reconstruction. There are pros and cons of each. With implants, recovery is faster, but they require monitoring and periodic replacement. With autologous reconstruction, surgery and recovery are longer, but no additional follow-up is needed once recovery is complete. The role of the plastic surgeon is to present all options and help patients choose what is right for them.

3. Determining eligibility for DIEP flap surgery

Patients who are good candidates for DIEP flap surgery have extra lower abdominal skin and fat. Being in good health also is important given the lengthy surgery and recovery period.

When it comes to age, there is no strict cutoff, although the risk of surgery increases for patients over age 65. Other issues, such as extensive abdominal surgeries and scarring or prior liposuction, may limit eligibility. Surgeons also carefully assess any issues related to bleeding, clotting or history of blood-thinning medication use.

Situations that increase risk require layered decision-making between patients and their surgeons. Mayo Clinic plastic surgeons are sometimes able to offer DIEP flap surgery for these patients, including those deemed ineligible elsewhere.

The team also helps patients overcome other contraindications to surgery. For example:

• Patients with a body mass index (BMI) over 35 receive resources to help them lose weight prior to surgery.
• Patients without excess abdominal skin or those with previous abdominal surgery can sometimes be candidates based on preoperative imaging. If the abdominal vascular anatomy is not favorable, a flap from the thigh or back may be an option. Note that prior C-sections and hysterectomies do not affect eligibility for DIEP flap surgery.

4. Providing options for secondary breast reconstruction

Patients often come to Mayo Clinic for secondary reconstructions, which may require specialized expertise. Common procedures include:

• Switch from an implant to a DIEP flap. Patients who initially choose implant-based breast reconstruction can transition to a DIEP flap.
• Delayed reconstruction. If patients had mastectomies without reconstruction, pursuing reconstruction later becomes more complex, especially if they've had radiation therapy. DIEP flap surgery is the most viable option.
• Revision due to complications or poor aesthetic outcome. These patients require detailed assessments of the prior reconstruction and careful surgical planning. The plastic surgery team is experienced in complex reconstructions and revisions.

5. Ensuring adequate tissue for breast reconstruction with a stacked flap

Patients with limited abdominal fat may have fewer reconstruction options. At Mayo Clinic, these patients can still pursue autologous breast reconstruction with stacked flaps. "We can gain more volume by stacking two flaps on top of each other in each breast," Dr. Harless says. The flaps might come from the abdomen, thighs or back. This procedure is highly specialized, and Mayo Clinic is one of a small number of hospitals where it is available.

6. Treating lymphedema during DIEP flap surgery

Lymphedema is a potentially serious and often life-altering complication of breast cancer treatment. Plastic surgeons can perform vascularized lymph node transfer during DIEP flap reconstruction to treat lymphedema and improve symptoms. The procedure involves transferring a lymph node from the groin to the armpit.

In addition, lymphatic reconstruction may be performed at the time of cancer surgery in patients at high risk— such as those treated with axillary lymph node dissection or radiation therapy and those with an elevated BMI — to reduce the likelihood of developing lymphedema.

7. Restoring nipple and breast sensation after mastectomy

Mastectomy causes a loss of sensation in the nipple and breast. New surgical techniques are helping improve sensation using nerve grafts.

"It's not an option for everyone, and long-term outcomes of resensation are still unknown. But if patients are concerned about sensation, we can assess them to see if they might benefit from this technique," Dr. Vijayasekaran says.

The specific procedure depends on the timing and type of breast reconstruction. The surgeon may connect the end of the intercostal nerve that was cut during mastectomy to nerves in the nipple or DIEP flap.

Originally, allografts were used to make the connection. A study published in Plastic and Reconstructive Surgery — Global Open in 2025 describes the use of autografts for nipple neurotization obtained by dissecting an intercostal nerve to gain length. As these techniques improve, patients will likely have better options for restoring sensation in their nipples and breasts.

8. Enhancing DIEP flap recovery

The plastic surgery team has implemented enhanced recovery after surgery (ERAS) protocols to help speed healing and reduce the risk of complications along the way.

ERAS for DIEP flap breast reconstruction includes:

• Prehabilitation. Patients undergo at least six weeks of physical therapy before surgery to strengthen their abdominal walls.
• Pain control. Surgeons perform nerve blocks to limit the need for narcotic pain medications. Most patients need only oral analgesics for pain control.
• Moving early. Nurses get patients up and moving as soon as possible after surgery to help prevent blood clots.

Hospital stays following surgery are usually 2 to 3 days. The first follow-up visit is at one week after discharge to check healing and remove any remaining drains. Patients who travel for care are asked to stay in the area until this visit. After that, they can meet with their surgeons and care teams virtually.

After three months, patients may return for a revision procedure. "We do our best to optimize the breasts' appearance during DIEP flap surgery," Dr. Harless says. "However, slight adjustments may become necessary as the breasts heal to improve symmetry or reduce scars. This outpatient surgery is the last step of breast reconstruction."

9. DIEP flap monitoring and salvage

Although DIEP flap failure is less than 1% according to the American Society of Plastic Surgeons, the plastic surgery team is vigilant about monitoring the flaps after surgery. The most common problem that occurs is clotting within the first 24 hours.

Plastic surgeons use two strategies to monitor DIEP flaps after surgery:

• Doppler monitoring. Doppler ultrasonography to assess blood flow in the flap is performed every hour for the first 24 hours. Monitoring can be done with an external Doppler device or an internal probe placed in the breast during surgery.
• Skin paddle. A skin paddle is a small piece of skin from the flap that the surgeon leaves visible on the breast's skin to allow for visual monitoring. The health of the paddle reflects the viability of the overall flap.

If the flap shows signs of failure, the surgeon takes the patient back to the operating room to check the microvascular connections. Quickly assessing the issue and making the needed adjustments helps rescue the flap in most patients.

"From our initial evaluation to surgery and recovery, we do everything possible to optimize each patient's outcome. After the long journey of breast cancer treatment, it's a privilege to help provide both physical and emotional restoration," Dr. Vijayasekaran says.

For more information

Millesi E, et al. Utilizing intercostal nerve autografts for nipple neurotization: A novel approach to restore sensation. Plastic Reconstructive Surgery — Global Open. 2025;13:e6898.

Refer a patient to Mayo Clinic.