Sydney

Breast DIEP

The main difference is the abdominal muscle. A TRAM flap takes a section of the rectus abdominis muscle along with the skin and fat, while a DIEP flap takes only skin, fat and blood vessels and leaves the muscle intact. Preserving the muscle lowers the risk of abdominal bulge and hernia and generally means a more comfortable recovery, which is why DIEP has largely replaced TRAM where a patient’s anatomy allows it. A/Prof Bish will assess whether your perforator vessels are suitable when planning your surgery.

A DIEP flap uses your own tissue, while implant reconstruction uses a prosthesis. Because a DIEP flap is built from your own fat, it feels closer to natural breast tissue, changes in volume as your weight fluctuates, and does not need to be replaced. Implant reconstruction is a shorter operation with a quicker initial recovery, but implants are not lifetime devices and carry their own risks, including capsular contracture, rupture and BIA-ALCL. There is no single right answer. The choice depends on your anatomy, your cancer treatment plan and your own preferences.

Yes. Breast reconstruction after mastectomy is reconstructive surgery rather than cosmetic surgery, so Medicare benefits apply. The MBS items for microsurgical reconstruction using a perforator flap are 46080 for a unilateral reconstruction and 46082 for a bilateral reconstruction performed by a single surgeon, with separate items where two surgeons operate together. Related items may also apply, including 45571 for closure of the abdomen and reconstruction of the belly button, and 45545 for nipple reconstruction. Surgery on the other breast for symmetry is also claimable. Out of pocket costs vary, and you will receive a written estimate before surgery.

No. The Medical Board of Australia guidelines that set the seven day cooling-off period, the two consultation requirement and mandatory psychological screening state that they apply to plastic surgery performed only for cosmetic or aesthetic reasons, and that they do not apply to reconstructive surgery. Breast reconstruction after mastectomy is reconstructive. In practice, the timing of your surgery is driven by your cancer treatment plan rather than by a waiting period. A referral is still required to see A/Prof Bish Soliman, and you will still have a full consultation and consent process before proceeding.

A unilateral DIEP flap usually takes around six to eight hours, and a bilateral reconstruction takes longer because two flaps are raised and two sets of blood vessels are joined. Most patients stay in hospital for several days so the flap can be monitored closely. The first 48 to 72 hours matter most, because that is when the blood supply to the flap is most at risk, so nursing staff will check the flap regularly through the day and night. Drains are usually in place for the first few days.

Most patients need around six to eight weeks before returning to normal daily activities, and longer before strenuous exercise or heavy lifting. The first two weeks at home are usually the hardest, and you will need help with driving, shopping and caring for children. Some abdominal tightness is normal early on and eases as you straighten up. Swelling settles gradually, the final shape continues to develop over six to twelve months, and scars keep fading for up to two years. Recovery varies from person to person.

Total flap loss is uncommon. Published series report total DIEP flap failure at roughly 1 to 2 per cent, and one single centre review of 3,270 DIEP flaps reported a failure rate of 1.22 per cent, lower for unilateral reconstruction and higher for bilateral. A small number of patients need to return to theatre in the first few days so the blood vessels can be checked, and that early return is often what saves a flap. If a flap cannot be saved, other reconstruction options remain available. A/Prof Bish will discuss the risks that apply to you.

Most women have reduced feeling in the reconstructed breast, at least at first. The mastectomy itself divides the nerves that supply the breast skin, so some loss of sensation is expected regardless of how the breast is reconstructed. Sensation often returns in part over months to years as nerves regenerate, although it is usually not the same as before surgery. In selected cases, a sensory nerve in the flap can be joined to a nerve in the chest, which may improve the return of feeling. A/Prof Bish will discuss whether this is appropriate for you.

Radiotherapy affects implant reconstruction more than it affects a DIEP flap. Where radiotherapy has been given or is planned, implant based reconstruction is generally discouraged because complication rates are considerably higher, including capsular contracture and loss of the implant. A DIEP flap tolerates radiotherapy better because it is living tissue with its own blood supply, although radiotherapy can still cause firmness, some shrinkage and changes to the skin. Where radiotherapy is planned, reconstruction is often delayed until treatment is complete. Your radiation oncologist and A/Prof Bish will plan the timing together.

Yes to both. There is no time limit on breast reconstruction in Australia, and a DIEP flap can be performed years or even decades after a mastectomy. Delayed reconstruction is common, particularly where chemotherapy or radiotherapy came first. If you already have an implant reconstruction, it can usually be converted to a DIEP flap provided you have enough lower abdominal tissue. Previous abdominal surgery such as a caesarean is rarely a barrier. A previous abdominoplasty usually rules out a DIEP flap, because the tissue and its blood supply have already been moved.

A laparoscopic DIEP flap uses keyhole surgery to dissect the flap blood vessels through the abdominal wall, rather than opening the muscle sheath from the outside. A/Prof Bish Soliman and his colleagues were among the first surgeons to perform this technique in Australia, and he presented the first Australian experience at the Royal Australasian College of Surgeons Annual Scientific Congress in 2023. The aim is to reduce disruption to the abdominal wall, which may further lower the risk of bulge or hernia and support a more comfortable recovery. The technique is not suitable for everyone, and A/Prof Bish will explain whether it is appropriate in your case.