Breast reconstruction with your own tissue · New York and New Jersey
DIEP Flap Breast Reconstruction
A DIEP flap rebuilds the breast after a mastectomy with your own skin and fat from the lower abdomen, usually with no implant. Dr. Steven Ovadia is a board certified plastic surgeon who performs DIEP, TRAM, and latissimus flap reconstruction, with offices in New York City and New Jersey.
Overview
Reconstruction with your own tissue
In autologous reconstruction, also called flap reconstruction, the breast is rebuilt with skin and fat moved from another part of your body. The tissue keeps a blood supply, so it heals into place as living tissue and becomes part of you.
Dr. Ovadia performs flaps from the abdomen and from the back. The DIEP flap and the free TRAM flap use the lower abdomen and are connected in the chest with microsurgery. The pedicled TRAM flap uses the same tissue and stays attached to its blood supply through the abdominal muscle. The latissimus flap uses the back and also stays attached to its own blood supply. He also performs implant-based reconstruction, and he goes over every option with you.
Why patients choose their own tissue
It feels like part of you
The new breast is made of living skin and fat. It is soft and warm, and it moves more like a natural breast than an implant does.
It changes with your body
Because it is your own tissue, the reconstructed breast gains and loses with your weight and ages along with the rest of you.
Often no implant at all
A flap from the abdomen usually rebuilds the breast without an implant, so there is no implant to monitor or replace over the years.
It holds up better to radiation
Radiation is harder on implants than on your own tissue. For patients who need radiation, a flap is often the more reliable long-term plan.
A way forward after implants
When an implant reconstruction has not worked out, from capsular contracture, repeated problems, or simply not liking it, it can be changed to your own tissue.
A lasting result
The operation and recovery are bigger up front. Once healed, a flap reconstruction generally needs less upkeep over the years than an implant.
Your own tissue is not the best plan for everyone. A flap is a longer operation with a second surgical area to heal, and it needs enough tissue to give. Implants, your own tissue, or a combination can each be the right answer.
The flaps
DIEP flap vs. TRAM flap vs. latissimus flap
Each of these flaps rebuilds the breast with your own skin and fat. They differ in where the tissue comes from, how much muscle comes with it, how it keeps its blood supply, and whether an implant is part of the plan.
DIEP flap
From the lower abdomen · free flap
Skin and fat from the lower abdomen, the same tissue removed in a tummy tuck, are moved to the chest with their blood vessels and connected under the microscope.
- The abdominal muscle is left in place
- Usually rebuilds the breast with no implant
- Leaves a scar low across the abdomen, from hip to hip
Free TRAM flap
From the lower abdomen · free flap
The same skin and fat as a DIEP flap, connected in the chest the same way, with a small piece of the abdominal muscle kept around the blood vessels.
- A small piece of muscle comes with the vessels
- Usually rebuilds the breast with no implant
- Leaves the same scar as a DIEP flap
Latissimus flap
From the back · pedicled flap
Skin, fat, and the latissimus muscle from the upper back are turned around to the front of the chest. The flap stays attached to its own blood supply in the armpit the whole time.
- No vessels are cut and reconnected
- Often combined with an implant or tissue expander
- Leaves a scar on the back, often placed where a bra strap sits
Side by side
| Compared | DIEP flap | Free TRAM flap | Latissimus flap |
|---|---|---|---|
| Where the tissue comes from | The lower abdomen | The lower abdomen | The upper back |
| Blood supply | Disconnected, then reconnected to vessels in the chest under the microscope | The same as a DIEP flap | Stays attached in the armpit; the flap is turned to the front |
| Muscle | The abdominal muscle is left in place | A small piece of the abdominal muscle comes with the vessels | The latissimus muscle moves with the flap |
| Implant | Usually none | Usually none | Often combined with an implant or expander |
| Scar where the tissue came from | Low across the abdomen, hip to hip, with a new opening for the belly button | The same as a DIEP flap | On the back, often along the bra line |
| The operation | Longer, with microsurgery and a hospital stay | The same as a DIEP flap | Shorter than a flap from the abdomen |
| Often chosen when | There is enough tissue on the lower abdomen and you would rather not have an implant | The vessels are small or spread out, and a cuff of muscle around them makes the blood supply more reliable | The abdomen is not an option, or to bring healthy skin and muscle cover to an implant reconstruction |
Dr. Ovadia also performs the pedicled TRAM flap, which uses the same tissue as a free TRAM and stays attached to the abdominal muscle.
Flaps from the abdomen
The DIEP flap procedure, step by step
DIEP stands for deep inferior epigastric perforator, the name of the blood vessels that feed the skin and fat of the lower abdomen. A DIEP flap moves that skin and fat to the chest with those vessels and leaves the abdominal muscle where it is.
Because the flap is fully detached and then connected again in the chest, it is called a free flap. Joining vessels only a few millimeters wide is called microsurgery.
Step 1
The tissue is lifted
An ellipse of skin and fat is taken from the lower abdomen, between the belly button and the pubic area, along with the small blood vessels that feed it.
Step 2
The muscle is left in place
Those vessels, called perforators, run through the abdominal muscle. They are carefully separated from it, so the muscle itself stays behind.
Step 3
Connected under the microscope
In the chest, the flap's artery and vein are joined to blood vessels next to the breastbone. The vessels are only a few millimeters wide, so this is done with microsurgery.
Step 4
Shaped into a breast
The flap is then shaped into the breast. The abdomen is closed much like a tummy tuck, and the belly button is brought out through a new opening.
The free TRAM flap
When a small piece of muscle comes with the flap
Muscle-sparing free TRAM
TRAM stands for transverse rectus abdominis myocutaneous. A free TRAM flap uses the same skin and fat as a DIEP flap and is connected in the chest the same way, with microsurgery. The difference is that a small piece of the rectus muscle, the long vertical muscle of the abdomen, comes with the blood vessels instead of being separated from them entirely.
- It is used when the blood vessels to the skin and fat are small or spread out. Keeping a small cuff of muscle around them gives the flap a more reliable blood supply
- The choice between a DIEP and a free TRAM can be made during surgery, once the vessels can be seen
- As little muscle as possible is taken, and most of the muscle and the nerves that supply it stay in place. Taking more muscle can add to the chance of weakness or a bulge in the abdomen
- The scar on the abdomen, the reconstructed breast, and the recovery are much the same as with a DIEP flap
The pedicled TRAM flap
When the flap stays attached to the muscle
Dr. Ovadia also performs the pedicled TRAM flap. It uses the same skin and fat of the lower abdomen, but the flap is never disconnected.
- The skin and fat stay attached to the rectus muscle, which carries their blood supply. The flap is passed under the skin of the upper abdomen to the chest
- No vessels are cut and reconnected, so no microsurgery is needed
- Because the muscle moves with the flap, weakness or a bulge in the abdomen is more likely than with a DIEP or free TRAM flap
- The scar on the abdomen is the same as with a DIEP flap
- Dr. Ovadia goes over whether a DIEP, a free TRAM, or a pedicled TRAM fits you best
Who is a candidate for a DIEP flap
What decides whether a flap from the abdomen fits
- There needs to be enough skin and fat on the lower abdomen to make a breast the size you want. Very lean patients may not have enough
- Earlier abdominal surgery, such as a C-section, often does not rule it out. Some operations, such as an earlier tummy tuck, usually do
- If you are planning a future pregnancy, tell Dr. Ovadia. It is often recommended to have a flap from the abdomen once you have finished having children
- Both breasts can be rebuilt at the same time, with the lower abdomen divided between the two sides
- Nicotine and some medical conditions affect blood flow in a flap. Dr. Ovadia goes over your health history with you
The abdomen is closed much like a tummy tuck, with a scar low across the abdomen from hip to hip. Many patients notice a flatter abdomen afterward. That is a side effect of the operation, not its purpose.
Latissimus flap
Latissimus dorsi flap reconstruction
The latissimus dorsi flap brings skin, fat, and muscle from the upper back to the front of the chest. Dr. Ovadia performs it as a pedicled flap: it never leaves its blood supply, so no microsurgery is needed to connect it.
Pedicled: it stays attached
The latissimus is a broad, flat muscle across the back. Its blood supply enters near the armpit. The flap keeps that connection and is passed under the skin of the armpit to the front of the chest, so no vessels are cut and reconnected.
Often paired with an implant
The back gives less volume than the abdomen, so the flap is often combined with an implant or a tissue expander. The flap adds healthy skin and a layer of muscle over the implant. For a smaller breast it can sometimes be enough on its own, with fat grafting.
When it is often chosen
When the abdomen does not have enough tissue or has had earlier surgery, when the chest skin has been treated with radiation, or to rescue an implant reconstruction where the skin over the implant is thin or damaged.
Your back and shoulder
Most patients go back to their usual activities. Some notice less strength in movements that pull the arm down and back, such as rowing or climbing. Fluid collecting under the skin of the back is the most common problem after this flap.
When a latissimus flap is combined with an implant, the implant has the same long-term considerations as in any implant-based reconstruction. Dr. Ovadia uses only smooth implants.
Timing
When the flap is done
For a flap from the abdomen, Dr. Ovadia places a tissue expander at the mastectomy and does the flap in a later operation, once you have healed and finished treatment. He plans the timing together with your breast surgeon and your oncologists.
Expander first, then the flap
Starting at the mastectomy
For a DIEP or free TRAM flap, Dr. Ovadia places a tissue expander at the time of the mastectomy. It holds the space and keeps the skin of the breast while you heal and finish treatment, including radiation if you need it. The flap is done in a later operation, and the expander comes out then.
Delayed
Months or years later
Reconstruction can also be done in a delayed fashion, after you have healed and finished treatment. Patients who had a mastectomy years ago, or who were not offered reconstruction at the time, can still have it.
Changing from implants
For a reconstruction you already have
An implant reconstruction can be changed to your own tissue, whoever did the first surgery. The implant is removed and the breast is rebuilt with a flap in the same operation.
If you have just been diagnosed, it helps to meet a plastic surgeon before your mastectomy, while all of the options are still open.
Finishing steps
Shaping and fat grafting
A second, smaller operation
A few months after the flap, many patients have a shorter operation to refine the shape of the breast. Fat grafting can fill in hollows, and the abdominal or back scar can be adjusted at the same time.
Matching the other breast
Symmetry surgery
When one breast is reconstructed, the other can be lifted, reduced, or made larger so that the two match.
The nipple and areola
Reconstruction and tattooing
When the nipple can be kept at the mastectomy, it is. When it cannot, a nipple can be rebuilt once the breast has settled, and tattooing can be performed to recreate the coloration of the areola.
Real results
DIEP flap before and after
These are Dr. Ovadia's own patients. Reconstruction is often done in stages, so each case notes what was done and how far out from surgery the "after" photo was taken.
Before-and-after photographs
This section contains before and after photographs of real surgical procedures.
You must be 18 years or older to view this content.
Recovery
DIEP flap recovery: what to expect
In the hospital
A DIEP or free TRAM flap means a hospital stay, usually a few days. In the first days the flap is checked often, including its color, warmth, and blood flow, because any problem with the connected vessels is most likely early and is best caught quickly. A latissimus flap usually means a shorter stay.
Drains are commonly used
Drains are commonly used, in the breast and where the tissue was taken. They are thin tubes that remove fluid while you heal. You are taught how to empty them before you go home, and they are removed in the office.
Your abdomen, after a DIEP or TRAM flap
The abdomen feels tight at first, and you walk slightly bent at the waist for the first days. Walking starts early. Lifting and exercise come back in steps over several weeks, as Dr. Ovadia advises.
Your back, after a latissimus flap
The back and shoulder are sore at first. Gentle arm movement starts early, and reaching, lifting, and exercise return in steps. Fluid can collect under the back skin after the drain comes out, and it can be drained in the office.
Swelling and garments
Swelling is normal and expected. You are told which garments to wear and when. Nothing tight should press on a new flap in the first days, because pressure can affect its blood flow.
A break from nicotine
Nicotine narrows blood vessels and affects healing, in the flap and where it came from. If you smoke or vape, Dr. Ovadia goes over taking a break from nicotine before and after surgery.
Call the office right away if the reconstructed breast changes color (paler, darker, or bluish), feels cooler, or suddenly swells or becomes firm, especially in the first week. Also call for spreading redness, drainage from an incision, or a fever. These are best taken care of early.
A general timeline, for a flap from the abdomen
This is a general guide. Everyone heals differently, and cancer treatment can change the timing. During your recovery, Dr. Ovadia will review your timeline with you.
Long term
Living with a DIEP flap reconstruction
Once it has healed, a flap reconstruction is part of your body. These are the points every patient should understand before surgery.
It is your own tissue
Once healed, the flap is living tissue. It gains and loses with your weight, and it ages with you. A large change in weight changes the reconstructed breast too.
No implant to replace
A flap from the abdomen without an implant has no device to monitor, exchange, or image for rupture. A latissimus flap with an implant has the same long-term considerations as any implant.
Living with an implantFirm areas in the flap
Part of the fat in a flap can harden into a firm lump, called fat necrosis. It is not cancer and is often harmless, but any new lump in a reconstructed breast should be checked, and imaging can tell the difference.
The abdominal wall
A DIEP flap leaves the abdominal muscle in place, and a free TRAM takes only a small piece of it. A pedicled TRAM moves the muscle with the flap, so weakness, a bulge, or a hernia in the abdomen is more likely with it. These can happen after any flap from the abdomen, and they can be repaired.
Feeling in the breast
The skin of a reconstructed breast usually has less feeling than before, and the skin of the flap starts out with little. Some feeling can return over time, more so in some patients than others. No technique can guarantee sensation.
Follow-up after cancer
Reconstruction does not change your cancer follow-up. Your breast surgeon and oncologists tell you what exams and imaging you need, for the reconstructed breast and for the other breast.
Cost and insurance
Is DIEP flap reconstruction covered by insurance?
Breast reconstruction after a mastectomy is not cosmetic surgery. A federal law, the Women's Health and Cancer Rights Act of 1998, requires most health plans that cover mastectomy to also cover reconstruction.
What the law requires those plans to cover
Women's Health and Cancer Rights Act
- All stages of reconstruction of the breast on which the mastectomy was performed
- Surgery and reconstruction of the other breast to produce a symmetrical appearance
- Prostheses
- Treatment of physical complications of the mastectomy, including lymphedema
Your plan's deductibles and coinsurance still apply, and every plan has its own rules and its own process for approval. Coverage is not guaranteed. The law applies to every stage of reconstruction, not only the first operation. That includes later surgery to refine the shape, surgery on the other breast for symmetry, and nipple reconstruction.
If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Your surgeon
Board certified and double fellowship-trained
Dr. Ovadia is board certified by the American Board of Plastic Surgery. After his plastic surgery training he completed two fellowships: gender-affirming surgery and microsurgery at Johns Hopkins, and craniofacial and pediatric plastic surgery at UT Austin / Dell Children's Hospital.
He performs breast reconstruction with the patient's own tissue and with implants, and he works alongside breast surgeons and oncologists at hospitals in New Jersey. He sees patients in New York City and in Jersey City and Millburn, New Jersey.
Questions
Common questions about DIEP flap reconstruction
What is a DIEP flap?
DIEP stands for deep inferior epigastric perforator, the name of the blood vessels that feed the skin and fat of the lower abdomen. In a DIEP flap that skin and fat are moved to the chest with those vessels, which are connected to blood vessels in the chest under the microscope. The abdominal muscle is left in place, and the abdomen is closed much like a tummy tuck.
What is autologous breast reconstruction?
Autologous means using your own tissue. The breast is rebuilt with skin and fat, and sometimes muscle, moved from another part of your body, most often the lower abdomen or the back. It is also called flap reconstruction. Dr. Ovadia performs the DIEP flap and the TRAM flap, free or pedicled, from the abdomen, and the latissimus flap from the back.
What is a free TRAM flap, and how is it different from a DIEP flap?
TRAM stands for transverse rectus abdominis myocutaneous. A free TRAM flap uses the same skin and fat of the lower abdomen as a DIEP flap and is connected in the chest the same way, with microsurgery. The difference is that a small piece of the rectus muscle is taken along with the blood vessels, instead of separating the vessels from the muscle entirely. It is often called a muscle-sparing free TRAM. It is used when the vessels are small or spread out, and the choice can be made during surgery. It is different from a pedicled TRAM, in which the flap stays attached to the muscle and is passed under the skin up to the chest. Dr. Ovadia performs both.
What is a latissimus flap, and what does pedicled mean?
The latissimus dorsi is a broad, flat muscle across the back. In a latissimus flap, skin, fat, and the muscle are turned around to the front of the chest. Pedicled means the flap stays attached to its own blood supply, which enters near the armpit, so no vessels are cut and reconnected. It is often combined with an implant or a tissue expander.
Which flap is right for me?
It depends on your body, your cancer treatment, any earlier surgery, and what matters most to you. A flap from the abdomen, DIEP or free TRAM, usually rebuilds the breast with no implant, when there is enough tissue on the lower abdomen. A latissimus flap is a shorter operation and is often chosen when the abdomen is not an option or to add healthy skin and muscle over an implant. Dr. Ovadia goes over both with you, along with implant-based reconstruction.
Will I need an implant?
With a DIEP or free TRAM flap, usually not. With a latissimus flap, often yes, because the back gives less volume than the abdomen. For a smaller breast a latissimus flap can sometimes be enough on its own, with fat grafting.
Is the flap done at the same time as my mastectomy?
Reconstruction starts at the mastectomy, but the flap itself is done later. For a DIEP or free TRAM flap, Dr. Ovadia places a tissue expander in the same operation as the mastectomy, working alongside your breast surgeon. It holds the space while you heal and finish any treatment, including radiation, and the flap is done in a later operation. Dr. Ovadia plans the timing with your breast surgeon and oncologists.
I already have implants. Can I change to my own tissue?
Yes. An implant reconstruction can be changed to a flap reconstruction, whether the implants were placed by Dr. Ovadia or by another surgeon. Patients choose this for capsular contracture, repeated problems with an implant, changes after radiation, or because they would rather not have an implant.
Am I a candidate for a DIEP flap?
You need enough skin and fat on the lower abdomen to make the breast. Many patients who have had a C-section or other abdominal surgery are still candidates, while some operations, such as an earlier tummy tuck, usually rule it out. If you are planning a future pregnancy, it is often recommended to wait. Dr. Ovadia examines your abdomen at your consultation and, when needed, reviews imaging of the blood vessels before surgery.
What happens to my stomach after a DIEP flap? Will it be flatter?
The abdomen is closed much like a tummy tuck. There is a long scar low across the abdomen, from hip to hip, and the belly button is brought out through a new opening. Many patients notice a flatter abdomen. Because the muscle is left in place, weakness, a bulge, or a hernia are less common than with flaps that take the muscle, but they can happen.
Where are the scars after a DIEP flap?
On the abdomen, a long scar runs low from hip to hip, placed so it can usually be hidden by underwear, with a small scar around the belly button. On the breast, the scars depend on the mastectomy. Scars are red at first and fade and flatten over many months. A later shaping operation can adjust them if needed.
DIEP flap or implants: which is better?
Neither is better for everyone. A DIEP flap is a bigger operation with a second area to heal, but it usually needs no implant and generally needs less upkeep over the years, and it holds up better to radiation. Implant-based reconstruction is a shorter operation and recovery, with no scar on the abdomen. Dr. Ovadia goes over both with you.
What are the risks of DIEP flap surgery?
Like any major surgery, a DIEP flap has risks, including bleeding, infection, fluid collection, slow healing along the incisions, and blood clots in the legs or lungs. Risks specific to a flap include a problem with the connected vessels, which can threaten the flap, firm areas of fat in the breast, and weakness or a bulge in the abdomen. Dr. Ovadia goes over your own risks with you at your consultation.
Will I lose strength in my shoulder after a latissimus flap?
Most patients go back to their usual activities, including exercise. Some notice less strength in movements that pull the arm down and back, such as rowing or climbing. The other muscles of the back and shoulder take over much of the latissimus muscle's work.
How long is the hospital stay and the recovery?
A DIEP or free TRAM flap means a hospital stay, usually a few days, with frequent checks of the flap. A latissimus flap usually means a shorter stay. Recovery takes several weeks, with lifting and exercise brought back in steps. Dr. Ovadia goes over what to expect for your surgery, and your timeline, with you.
Can both breasts be reconstructed with a DIEP flap?
Yes. When both breasts are reconstructed, the tissue of the lower abdomen is divided between the two sides, with one flap for each breast. The scar on the abdomen is the same.
What if the flap does not survive?
In a small number of cases the connected blood vessels clot. This is most likely in the first days after surgery, which is why the flap is watched closely in the hospital. When it is caught early, a return to the operating room can often save the flap. If a flap is lost, other options for reconstruction remain.
Will my reconstructed breast have feeling?
A mastectomy removes many of the small nerves that give the breast its feeling, and the skin of a flap starts out with little feeling. Some feeling can return over time, more so in some patients than others. No technique can guarantee sensation.
Will the reconstruction change if I gain or lose weight?
Yes. The flap is your own fat, so it gains and loses along with the rest of your body. A large change in weight changes the reconstructed breast too.
Is DIEP flap reconstruction covered by insurance?
Federal law, the Women's Health and Cancer Rights Act, requires most health plans that cover mastectomy to also cover all stages of reconstruction, surgery on the other breast for symmetry, prostheses, and treatment of physical complications of the mastectomy. Your plan's deductibles and coinsurance still apply, and every plan has its own rules. If you have questions about possible insurance coverage for surgery, call or email us and we will go over it with you.
Can I have a consultation without coming to the office?
Yes. Phone and video consultations are available, in addition to in-person visits in New York City, Jersey City, and Millburn, New Jersey.
Next step
Start with a consultation
Dr. Ovadia will examine you, go over your options, and explain what he recommends and why. If you have a date for your mastectomy, or records from surgery you have already had, let us know when you call.
225 Broadway, Suite 3100, New York, NY
377 Jersey Ave, Suite 440, Jersey City, NJ
90 Millburn Ave, Suite 206, Millburn, NJ
Phone and video consultations available · info@ovadiaps.com