DIEP flap (Deep Inferior Epigastric Perforator) breast reconstruction uses skin and fat from the abdomen to rebuild the breast, without sacrificing the rectus abdominis muscle. A microsurgical technique that restores a natural breast, without implants, with a definitive and evolving outcome.
The DIEP flap is an autologous breast reconstruction technique that uses skin and fat from your own abdomen — without sacrificing any muscle. It is the reference when you want a fully natural, evolving reconstruction that follows weight fluctuations like a natural breast.
The procedure involves dissecting a horizontal ellipse of skin and fat from the infraumbilical abdominal region. The flap is harvested with an artery and a vein — the deep inferior epigastric perforator vessels — but without the rectus abdominis muscle or its fascia, which are carefully preserved.
The flap is then transferred to the chest. Its vessels are reconnected under a microscope to vessels of the axilla or chest: this microsurgical step keeps the tissue alive. Dr Zeitoun does not perform microsurgery himself — this part of the procedure is carried out in close collaboration with an experienced plastic microsurgeon. The flap is then shaped to rebuild a natural breast, without any prosthetic material.
The reconstructed breast is definitive and evolving: it follows weight fluctuations and the effects of gravity like a natural breast. The improved abdominal silhouette (tummy tuck effect) is often perceived as a bonus.
Breast reconstruction is never mandatory. It remains a personal choice, discussed in consultation without pressure or imposed deadline. Other techniques exist — latissimus dorsi flap, implant reconstruction, flat closure — each with its own pros and cons.
DIEP is the reference technique when a fully autologous reconstruction without implants is desired — provided the abdominal apron is sufficient and the patient meets the criteria for a multi-hour microsurgical procedure.
DIEP requires a sufficient abdominal apron — enough infraumbilical skin and fat to reconstruct the desired breast volume. Reconstruction comes with an improved abdominal silhouette.
Radiotherapy weakens the chest wall skin and makes any implant-based reconstruction risky. Non-irradiated abdominal tissue provides healthy, high-quality coverage and yields far superior results in this context.
For patients who do not want foreign material, or after complications on prosthetic reconstruction (capsular contracture, exposure, rupture), DIEP offers a definitive and fully autologous solution.
When a large breast volume needs to be rebuilt, DIEP provides significant autologous volume without limitation — where latissimus dorsi alone would be insufficient and a large implant would be poorly tolerated.
DIEP is contraindicated in active smokers (risk of flap necrosis), in morbid obesity, after extensive prior abdominal surgery, in poorly controlled diabetes, or in cardiorespiratory conditions incompatible with a long procedure.
DIEP is the most refined of abdominal flaps. It fully preserves the rectus abdominis muscle and its fascia, unlike the traditional TRAM flap. The flap is kept alive by microsurgery — only the perforator vessels are dissected through the muscle, which remains intact.
In the traditional TRAM flap, the rectus abdominis muscle and its fascia are harvested along with the skin and fat, which weakens the abdominal wall and often requires synthetic mesh reinforcement.
In DIEP, only the perforator vessels are dissected through the muscle, which is preserved intact. No synthetic reinforcement is needed, wall weakening is minimal, and strength loss remains low (less than 30% on the operated side).
DIEP breast reconstruction is often completed by contralateral symmetrisation and nipple-areola complex reconstruction. These procedures are planned later, once the reconstructed breast volume has stabilised — usually 3 to 6 months afterwards.
Breast fat grafting (lipofilling) can also be added to refine the contours of the reconstructed breast and correct any irregularities.
DIEP is a complex procedure that combines breast oncological surgery with microsurgery. Dr Zeitoun, a breast and gynaecologic oncologic surgeon, does not personally perform the microsurgical step — fine dissection of perforator vessels and vascular reconnection under a microscope are carried out by an experienced plastic microsurgeon.
This close collaboration ensures optimal care: each phase of the procedure is entrusted to the surgeon most expert in that field. Dr Zeitoun handles the preoperative oncological workup, the mastectomy and full follow-up — the plastic microsurgeon performs flap harvest, microvascular anastomoses and shaping of the reconstructed breast.
Nipple-areola complex (NAC) reconstruction and contralateral breast symmetrisation are systematically offered in a second stage, once the reconstructed breast volume has stabilised. These procedures are also reimbursed by the French National Health Insurance. DIEP reconstruction does not affect oncological surveillance in any way — follow-up is maintained with the same rigour.
A CT angiogram of the abdominal vessels is systematic — it allows planning of the procedure vessel by vessel. The anaesthetic consultation takes place no later than 48 hours before surgery. Contralateral breast imaging is re-done if older than one year.
You must purchase an abdominal compression garment that fastens at the front, to be worn continuously for several weeks from the first dressing change.
Smoking cessation is required at least 1 month before surgery and until full healing. A urinary nicotine test may be carried out on the day of surgery — if positive, the procedure may be cancelled. E-cigarettes are treated the same way.
Standard general anaesthesia. Anaesthetic consultation mandatory no later than 48 hours before surgery.
The procedure lasts 3 to 5 hours. Hospital stay of 3 to 5 nights, determined by microsurgical flap monitoring and drain removal.
Reimbursed on the Sécurité Sociale base under the ALD scheme for breast cancer. Additional fees sector 2 — written quote provided in consultation.
DIEP reconstruction immediately restores volume and shape, allowing you to dress normally with a décolletage. The result is particularly natural — autologous tissue has the look, texture and softness of a natural breast.
At first the breast may appear a little too tight, with a feeling of abdominal pulling. It takes 2 to 3 months to appreciate the final result, once tissues have stabilised. Some residual asymmetry (volume, shape, colour, sensation) is inevitable.
The scars — chest and lower abdominal — appear pink and raised for the first few months, then gradually fade without ever disappearing completely. The improved abdominal silhouette is often seen as a bonus.
The aim is to provide a marked improvement without claiming perfection. If expectations are realistic, the outcome should give you great satisfaction. Psychological integration of the reconstructed breast may take several months, during which medical and family support plays an important role.
DIEP flap breast reconstruction is a major surgical procedure. Serious complications are fortunately uncommon when surgery is performed by an experienced team, but it is important to know them in order to anticipate them.
This is the specific and most feared complication of DIEP. It occurs through thrombosis of the microvascular anastomoses — the delicate vascularisation of the flap, whose vessels are reconnected under a microscope, explains this risk. It is significantly higher in diabetic, overweight, or smoking patients.
Smoking cessation is therefore absolutely mandatory. Thrombosis inevitably leads to necrosis and requires re-operation to remove the flap — this is a reconstruction failure.
Smoking cessation mandatory ≥ 1 month before Close postoperative monitoringHaematoma is a risk inherent to any surgical procedure. It can occur despite all the attention given intraoperatively by the surgeon. This complication may require early surgical revision for evacuation and haemostasis.
Close postoperative monitoring Surgical revision if neededFat necrosis creates firm, painless nodules in the reconstructed breast. They are easily distinguished from disease recurrence through breast imaging, but their appearance can cause understandable anxiety. These nodules can be managed with fat grafting or surgical excision if needed.
Standard mammographic follow-up Corrective fat grafting if neededInfection is always possible but not frequent after DIEP. It requires appropriate antibiotic treatment and, more rarely, surgical revision. Perioperative antibiotic prophylaxis is systematic.
Systematic antibiotic prophylaxisThe procedure weakens the abdominal wall, but the risk of bulging is minimal with DIEP since the rectus abdominis muscle and its fascia are preserved. Sometimes the abdomen may show a small infraumbilical bulge at the vessel harvest site. This has no consequence for your health or comfort.
Hernia is also exceptional after a well-performed DIEP — this is one of the major advantages of this technique over the traditional TRAM.
Rectus abdominis preserved No synthetic mesh neededThrombo-embolic risks (deep vein thrombosis, pulmonary embolism) are fairly high with this type of reconstruction given the operative duration. The anaesthetist may prescribe anti-thrombotic compression stockings that you will need to wear from before surgery until discharge from hospital. Preventive anticoagulants are also prescribed.
Anti-thrombotic stockings before + after Preventive anticoagulationDIEP requires a sufficient abdominal apron — enough infraumbilical skin and fat to rebuild the desired breast volume. There must be enough tissue to reconstruct the breast in good conditions.
Very thin women without abdominal excess may not be eligible — in that case, other techniques are offered (latissimus dorsi, inner thigh flap). Morbid obesity is also a contraindication as it strongly increases complications.
Sufficient abdominal apron required Non-smoker mandatory Alternatives if morphology unsuitableRadiotherapy deeply alters the quality of chest wall tissues: the skin becomes less supple, less vascularised, more fragile. An implant placed under irradiated skin has a much higher risk of capsular contracture, infection or cutaneous exposure.
DIEP brings healthy, non-irradiated tissue from the abdomen to replace the damaged chest skin. The outcome is incomparably better in this context — it is one of DIEP's main indications.
Healthy non-irradiated tissue No implant under irradiated skin Reference technique post-radiotherapyThe abdominal scar is horizontal, infraumbilical, extending from hip to hip — similar to an abdominoplasty scar. It is generally well hidden under underwear and the bottom of swimsuits.
Scars appear pink and slightly raised for the first few months, then gradually fade without ever disappearing completely. The improved abdominal silhouette (tummy-tuck effect) is often perceived as a bonus by patients.
Concealable horizontal scar Added tummy-tuck effectUnlike the traditional TRAM that harvests the rectus abdominis, DIEP fully preserves the muscle and its fascia. No synthetic mesh is placed to reinforce the abdominal wall — it is unnecessary: not taking the rectus muscle and its fascia prevents weakening.
A residual loss of strength may exist on the operated side, but it is low — less than 30% — and may affect very athletic women without impacting daily life. The risk of hernia, frequent after TRAM, is minimal after DIEP.
Rectus abdominis preserved Strength loss < 30% Minimal hernia riskBreast reconstruction after breast cancer is fully covered at 100% by the French National Health Insurance based on the Sécurité Sociale tariff, under the ALD (long-term condition) scheme. This includes the DIEP flap, contralateral symmetrisation and nipple-areola complex reconstruction.
Dr Zeitoun practises under sector 2 non OPTAM. Additional fees apply. A detailed written quote is provided before any procedure. Your private health insurance may reimburse all or part of the extra fees depending on your policy.
100% national health base (ALD) Quote provided in consultation Private insurance may cover extra feesYes. The procedure can be performed immediately at the time of mastectomy — this is called immediate reconstruction — or later, after the mastectomy and any additional treatments that were needed: this is called delayed reconstruction.
In immediate reconstruction, the mastectomy scar is used as the surgical approach. It can sometimes be improved, but not made to disappear. The decision between immediate and delayed is discussed at a multidisciplinary team meeting (MDT) depending on your oncological situation.
Immediate or delayed MDT decisionEvery situation is unique. The consultation allows us to define together the technique best suited to your anatomy, your treatment history and your expectations.