DIEP Flap Breast Reconstruction Sydney

DIEP Flap Surgery TUG flap Risks & Complications FAQs Pricing

Breast cancer unfortunately affects 1 in 8 women in this country. In some families carrying certain genes such as BRCA1 or 2 the risk can be as high as 80% during a woman’s lifetime.

Treatment for breast cancer often involves lumpectomy or mastectomy and adjuvant treatments such as chemotherapy and radiotherapy. While the main breast cancer treatment will be mostly coordinated by your breast surgeon, Dr Aggarwal will work with you and the breast surgeon to offer you the best reconstruction possible.

Breast reconstruction empowers a woman to restore their physical appearance, regain confidence, and remove the stigmata of this illness.

The aim of breast reconstruction is to:

Create a breast mound
Look great in clothes (even tight fitting dresses)
Achieve symmetry with the opposite breast (in cases of one-sided or unilateral reconstruction)
Avoid the use of a prostheses

At Mode we aim to go one step further and will try to make your reconstruction look good even without clothes however this can be difficult to achieve as scars from mastectomy surgery will usually be visible, and perfect symmetry of a reconstructed breast to a native breast can be very difficult to achieve.

Breast reconstruction using DIEP or msTRAM flap can be:

immediate (at the time of mastectomy); or
delayed (after mastectomy and other treatment such as chemo and radiotherapy)

This is considered the Rolls-Royce of Breast Reconstruction. Patients who have had it want to tell the world about it, because it offers advantages unmatched by other forms of reconstruction:

The reconstructed breast feels soft and natural like a normal breast because it is built from your own tissue
If you were to put on weight the reconstructed breast will add on weight and vice versa.
The reconstructed breast will sag with age mimicking a normal breast
It is possible to mimic the shape of a larger, ptotic (saggy) breast which is impossible with implant based reconstructions
There are no long term risks and complications of implants, and no future repeat operations to exchange implants.
No risk of BIA-ALCL
Immediate autologous reconstruction can be difficult to tell from a breast lift or reduction when completed.

Who Is Autologous (Own Tissue) Breast Reconstruction good for?

Most women are good candidates for this type of surgery

Autologous or Free Flap Breast Reconstruction can be an excellent choice for you if:

You desire to restore your physical appearance and regain your confidence and femininity
You wish to look great in your usual clothes
You want a reconstruction that looks and feels like a normal breast
You don’t like the idea of having implant exchanges every 10-15 years (this can be particularly important if you are a young person)
You want to improve another area of the body such as the tummy
you don’t mind having surgery on the other breast to achieve symmetry (If having one sided breast reconstruction)
you don’t mind having a big operation upfront to avoid future repeat surgery

Autologous reconstruction becomes one of your only choices if:

You have had radiation:
- implants and radiation generally don’t mix well. The rates of complications, requiring revision of reconstruction, are as high as 30-40% in this scenario.
- This is because radiation causes collateral damage to the tissues increasing risks of
  - Device extrusion, and infection
  - Poor physical shape of the breast due to poor laxity and compliance of the breast soft tissues
  - Higher rate of capsular contracture (breast implants going hard)
- You are overweight (BMI 30-35)
- You have one breast that is large and droopy (ptotic) and you need a reconstruction on the opposite side to match it.
- You have poor quality soft tissues on the chest after breast cancer treatment
- You have previously failed implant breast reconstruction

Who Is Autologous or Free Flap Breast Reconstruction NOT good for?

Autologous or Free Flap Breast Reconstruction can have some significant complications, and you may not be a good candidate for it if you fall into the following categories:

You are obese (BMI >35)
You smoke
You have had previous clots in the legs or lungs, or carry a gene that predisposes to clotting
You are on blood thinners
You have multiple other medical problems that make you unsuitable for a long procedure

In addition a DIEP flap may not be possible if:

You are a skinny person and lack a sufficient amount of tummy tissue to harvest for reconstruction
You have previously had an abdominoplasty or DIEP flap
You have had an open cholecystectomy (gallbladder removal through a large incision on the tummy)
Have had multiple abdominal procedures
You have had surgery that divided the blood vessels used in DIEP or msTRAM surgery (this can include inguinal hernia repairs, emergency C sections, etc). * Dr Aggarwal will send you for a special CT scan prior to your surgery to evaluate the integrity of these blood vessels.

Dr Aggarwal

Dr Aggarwal is a well regarded, respected, highly skilled and experienced Specialist Plastic Surgeon. Graduating at the top of his class throughout his training, Dr Aggarwal has completed fellowship training at some of the world’s most prestigious reconstructive and cosmetic plastic surgery institutions in Canada and the USA. He continues to publish research is prestigious plastic surgery journals, and is actively involved in the training of future plastic surgeons.

What sets Dr Aggarwal apart from others is his personal, affable and warm nature. Not only does he pay attention to detail, to producing natural, beautiful results but he ensures that the patient’s journey is just as special as their outcome. Dr Aggarwal looks after patients at one of Sydney’s most prestigious public hospital campuses (POWH/SCH/RHW), and operates privately on Sydney’s North Shore. Dr Aggarwal has treated thousands of patients throughout Sydney and beyond who have achieved outstanding results under his care.

Procedure Snapshot

Anaesthetic: GA by accredited anaesthetist
Time: 4-6 hours for unilateral (one sided) reconstruction, 6-8 hours for bilateral reconstruction (both sides). Immediate reconstruction i.e. having mastectomy in the same operation can add 1-2 hours to surgery time.
Duration of stay: Requires usually a week of inpatient stay.
Hospital: Offered at most of the hospitals where Dr Aggarwal works
Medicare/Health Fund Rebate: Yes, if you have appropriate level of insurance cover.

Recovery: Patients start walking hunched over in the first day or two. By the end of the first week they are starting to feel normal and go home. At this stage one or more drains may still be in place. Heavy lifting or exercise is disallowed for 8 weeks and strenuous exercise for 3 months. For 8 weeks you will be required to wear a binder which is like a corset over the tummy. Avoid swimming in a pool or beach for 2-3 weeks until all wounds have healed, and all drains are out.
Results: Usually fantastic results can be achieved through DIEP or msTRAM. It can closely resemble the look and feel of a normal breast. Best results are achieved with immediate reconstruction but delayed reconstructions look good too. Results can vary from patient to patient largely due to variation in anatomy, breast size and if the reconstruction is unilateral (one sided) or bilateral (both sides).

DIEP Flap Surgery

What is an abdominal free flap for breast reconstruction?

In autologous breast reconstruction the skin and fat from the abdomen is used to reconstruct the breast.
This cannot simply be transferred to the chest as it needs a blood supply to keep it alive.
A free flap is where a block of tissue such as skin and fat from the tummy is taken with its blood supply. This blood supply courses through the underlying rectus (or six-pack) muscle.

This flap or block of tissue, once harvested, is then disconnected (and therefore for a period of time has no blood supply)
Blood vessels are then found in the chest (accessed via removal of part of the rib or by going between the ribs)
The blood supply of the flap is then connected to the blood vessels in the chest using a microscope or loupes. An artery is connected to deliver blood to the flap, and a vein is connected to take the blood away. Once connected the newly transferred tissue starts to bleed, and is living again.
In essence this is like having a transplant of tissue from one area of the body to another.

What is a DIEP and how does it differ to a TRAM?

A TRAM flap, a msTRAM flap, and a DIEP flap are variations of the same operation.
In all procedures the skin and fat from the abdomen or tummy is used to create a breast on one or both sides.
The detail is in how the blood vessels that keep this tissue alive are taken from the abdomen, and how much damage is caused to the rectus muscles.
Traditionally, plastic surgeons divided the entire rectus muscle and took it with the skin and fat as part of the flap. This was done to keep the tiny blood vessels that connect the muscle to the skin and fat (called perforators) protected. This is called the TRAM flap and is still performed in Sydney today.
- While this is still a good operation from a blood supply point of view, it is very damaging to the rectus muscle.
- The muscle defect is repaired using a mesh that prevents abdominal hernias. So strength of the tummy is still very good after this operation.
- However women who have a bilateral reconstruction, and have a bilateral TRAM flap will struggle to sit up from a lying position as both their rectus muscles have been taken. They will also require a large amount of mesh to repair their abdomen.
The other extreme is a DIEP flap. This is where the skin and fat of the tummy is taken without any of the underlying rectus muscle. The blood vessels that run through that muscle and the tiny blood vessels that connect to the overlying skin and fat (the perforators) are carefully dissected, and taken without the muscle.
- DIEP flap surgery requires additional training and experience, and is therefore not offered by all surgeons. Dr Aggarwal is one of the few Sydney plastic surgeons who routinely perform this surgery, and trained at one of the best microsurgical units in the world.
- Because the muscle and its overlying fascia is left behind little or no mesh is required to repair the tummy
- By preserving the muscle, its function is also preserved.
- However the downside of DIEP flap surgery is:
  - By keeping the muscle, only a few of the perforators can be kept and therefore the blood supply of the DIEP is less than what it would be with a TRAM
  - Whether a patient can have a DIEP flap is judged preoperatively on a special CT scan called a CT angiogram, and is judged during the operation on the size of those perforating arteries and veins.
- If safe to do so, Dr Aggarwal will always aim to perform a DIEP flap reconstruction.
There is a medium between the DIEP and TRAM called msTRAM which stands for muscle-sparing TRAM flap.
- This is when not all the muscle is sacrificed (as in TRAM)
- However a DIEP may also not be possible because the blood vessels piercing through to the skin and fat from the muscle are too small, and therefore the blood supply though them would not keep all the tissue alive
- In this scenario a small amount of muscle may be taken to capture additional blood supply and keep the tissue alive
- Because the amount of muscle and fascia taken is minimised the amount of mesh required for repair is much less than that needed for a TRAM flap
- Because some muscle is preserved, some function is also retained.

What sort of mastectomy do I have?

The decision of what type of mastectomy to perform is generally up to the breast surgeon
In Immediate reconstruction your mastectomy will be either:
- skin sparing (where the nipple is sacrificed, but the skin is spared) – here you will have a patch of skin from the tummy where the nipple and areola used to be; or
- occasionally nipple sparing (where skin and nipple of the breast is spared)
In delayed reconstruction you will generally have a standard mastectomy where the skin is closed resulting in a flat shape to the chest. Reconstruction is then carried out after treatment for breast cancer has been completed.
- Here you will have a large patch of abdominal skin on the chest to create the breast mound

What does the surgery involve?

After the breast surgeons complete the mastectomy blood vessels are found in the chest.
Simultaneously the flap is harvested from the tummy as indicated under description of DIEP.
The blood vessels are connected using loupes or microscope.
The flap is then shaped to mimic a breast and 1-2 drains are inserted. If reconstruction is bilateral the same is done on the opposite side.
The abdomen is closed much like a tummy tuck and 2 drains are inserted here also.
Because this is a long operation our team aims to work simultaneously and often comprises 2 plastic surgeons, specialist anaesthetist, 1-2 assistants, and 1 breast surgeon and their assistant.

What happens after my breast reconstruction surgery using DIEP or msTRAM?

You will have 1-2 drains inserted in each breast that you have reconstructed, as well as 2 drains in the tummy from where the flap was taken. These are inserted to collect the fluid that the body places in a site of injury and drains help reduce the chance of a fluid collection (seroma).
You will be kept in hospital for the first week after surgery to help you recover. Most importantly during the first 3 days you will have hourly checks by the nursing staff to check the blood supply to the flap(s). This is to detect any problems with the small blood vessels connected, on which the whole operation rests.
The first day after surgery you will largely be in bed with your back and legs up, and a catheter in place.
The following day you will walk hunched over (as the tummy will be tight), and we will aim to get your catheter out. The following days we will slowly disconnect you from lines and drains. You will be able to get all areas wet when you are down to 1 or 2 drains and the sites have been waterproofed.
You will not be allowed to swim in a pool or beach for at least 2 weeks after surgery or until all drains are removed (whichever is later).
It is possible that you may go home with some drains still in place.
You will be given a script for antibiotics by Dr Aggarwal which you must continue until all drains are removed. You will also be given appropriate pain relief medications.
When you go home it is best to have someone look after you for the first few weeks as you recover.
While most sedentary activities can be resumed when you go home, you must lay low and not exert yourself. You will also not be allowed to do any heavy lifting or exercises for the first 8 weeks. During this period you will also be required to wear an abdominal binder (resembles a corset).
At 2-3 weeks you can begin wearing a crop top or sports bra.
Dr Aggarwal will see regularly after your discharge from hospital.

Will I need further surgery?

Yes
If you had unilateral reconstruction you may require a breast lift or reduction of the opposite breast to match the reconstruction. Adjustments of the flap volume or scars can also be undertaken at this time. Patients may also elect to undergo nipple reconstruction.
If you had bilateral reconstruction, you may elect for a nipple reconstruction. Again scar revision or adjustments of volume to get better symmetry can also be undertaken at the second stage.

TUG flap

A TUG flap stands for transverse upper gracilis flap, and is located in the upper inner thigh.
This is the second choice for own tissue breast reconstruction for Dr Aggarwal, in patients who are not suitable for DIEP flaps (due to lack of tissue or previous abdominal surgery).
The basic concept of free flap transfer is the same – the tissue (skin, fat and a muscle called the gracilis) is taken with its blood supply. It is transferred to the chest where its blood supply is reconnected using loupes or a microscope.

What does the surgery involve?

After the breast surgeons complete the mastectomy blood vessels are found in the chest.
Simultaneously the flap is harvested from the upper inner thigh. Skin, fat and the underlying muscle called the gracilis is taken with its blood supply.
The blood vessels are connected using loupes or microscope.
The flap is then shaped to mimic a breast and 1-2 drains are inserted. If reconstruction is bilateral the same is done on the opposite side.
The inner thigh is closed much like a thigh lift, with 1 drain.
Because this is a long operation our team aims to work simultaneously and often comprises 2 plastic surgeons, specialist anaesthetist, 1-2 assistants, and 1 breast surgeon and their assistant.

Risks & Complications

General Complications

Risks of anaesthetic – there are general risks of going under an anaesthetic such as a stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of blotting in the legs. These risks are generally low in patients who are otherwise fit and healthy, however you will be required to wear compressive stocking and receive an injection to help prevent clots, whilst in hospital.
Bleeding (2%) – any bleeding is controlled during surgery however unexpected bleeding can occur in the immediate postoperative period. If this occurs it will necessitate a return to theatre to control the bleeding, as it can compromise the flap.
Infection (1-2%) – this is extremely rare as are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum. It is more common for occasional dissolving sutures to spit out and form a little pustule which settles once the suture is removed.
Seroma (3-5%) – A mastectomy is a reasonable ‘injury’ to the body, to which the body responds by accumulating fluid. Similarly the tummy from where the flap has been taken is a large space where fluid can accumulate. Drains are inserted during surgery to remove the excess fluid that your body does not absorb. Drains are only removed when the fluid reduces. If a fluid collection develops after removal of drains it may need to be removed via a needle through the skin. The fluid is removed as if it accumulates there is a risk of it getting infected.

Flap Complications

Return to theatre (<5%) – Hourly checks of your flap(s) will be conducted to detect any problems with the blood supply. If there is a concern you may need to be taken back to theatre to check the blood vessels that were connected – early detection of a problem allows us to rectify it, and salvage the flap. Dr Aggarwal’s actual return to theatre rate is <1% but we quote 5% so you are prepared for this risk.
Partial flap loss (2%) – It is possible that a part of the flap transferred for reconstruction may not have as good blood supply as initially thought and it slowly dies and turns black. If this happens it is usually of nuisance value as it requires a trip back to the operating room (which can be after you go home, as a day surgery or overnight stay procedure) to remove the lost area and resuture wounds.
Total flap loss (<1%) – it is possible (although improbable) that the whole flap does not survive the transfer. This is usually when there is a low grade venous problem and while the blood supply initially is good, the vein carrying blood away from the flap slowly blocks off. If it does so the blood backs up eventually blocking the artery and the whole flap dies a slow death. Fortuantely this is not a problem we have had, but you must be prepared for this before signing up for surgery. If it happens there are always other options for reconstruction.

Other Soft Tissue Complications

Mastectomy skin flap necrosis – removal of the breast tissue by the breast surgeon leaves behind the skin of the breast. Most of the blood supply to this skin is removed with the breast tissue, and therefore it is only nourished by blood vessels entering where the skin connects to the chest. If in parts the skin is very thin, it can lose its blood supply altogether and dies. This may require a clean up and sometimes a skin graft.
Abdominal hernia (1-2%) – this is less commonly a frank hernia, but if it occurs its usually a minor or moderate bulge. Can require a repeat procedure to reinforce the area with mesh.
Absence of skin (and nipple) sensation – this should be expected as normal as the removal of breast tissue takes with it the nerve supply to the overlying skin of the breast. The breast flap will also remain insensate for life.
Asymmetry
- Most women’s breasts are asymmetrical and therefore the mastectomy performed is also asymmetrical in bilateral reconstruction.
- In unilateral reconstruction it is very challenging to match the reconstruction to a normal breast, although much better than implant based reconstruction.
- While the aim is to achieve symmetry adjustments of the flap volume may need to be made at secondary surgery, and a breast lift may need to be performed on the opposite breast
Hypertrophic or poor scars – You will have a long scar on the lower tummy from hip to hip in addition to those on the breast. The long scar on the tummy resembles a tummy tuck and can usually be hidden under clothes or swim-wear. However all scars slowly fade and become less obvious with time, though never disappear. How one’s body behaves to scarring is individual and largely genetic. Some types of skin are more prone to hypertrophic or keloid scarring, and some individuals and families are more prone to this. We will routinely advise you on how to improve the quality of scars over time. You should also discuss any history of abnormal scarring with Dr Aggarwal preoperatively.

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Procedure FAQs

Do I need a referral for breast reconstruction?

It is advisable to obtain a referral for breast reconstruction as it is possible to claim a Medicare rebate of approximately $73 for the consultation if you have a referral
A Medicare/Health Fund rebate may apply to you depending on your level of cover, and having a referral allows you to claim this.

Where can I see Dr Aggarwal?

You can see Dr Aggarwal at the main rooms in Gordon, and he also consults at Hornsby, Hunters Hill and Camperdown.
Please scroll to the bottom of the page to find out more information about these locations

Where will I have my operation?

At any of the hospitals where Dr Aggarwal works.

What can I do to prepare for surgery?

Stop smoking well in advance of surgery. The risk of mastectomy skin flap necrosis and wound healing problems increases significantly in patients who smoke. Dr Aggarwal also does not offer free flap breast reconstruction to active smokers.
Cease fish oil, and other supplements such as Ginkgo, Ginseng.
Please discuss with Dr Aggarwal if you are on blood thinning medications

After surgery, will I need to wear a special surgical bra?

No but you are advised to wear a tight fitting crop top or sports bra starting at 2-3 weeks post surgery, for at least 6 weeks.
You should not wear any bras with an underwire during this period
You will also be required to wear an abdominal binder for 8 weeks.

Will I be able to exercise after surgery?

You will struggle to walk straight immediately after surgery given the tension in the tummy. You will need to walk hunched over initially but you straighten a little day by day.
Heavy lifting and exercise will need to be avoided for 8 weeks to allow the abdominal tissues to heal.
Heavy gym exercise will need to be discontinued for 3 months.

Will I need special medications after surgery?

Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.
In general antibiotics are continued until all drains are out
Your pain relief requirements will decrease day by day but can continue for several weeks after surgery

Will I need further surgery?

Most likely.
If you had unilateral reconstruction you may require a breast lift or reduction of the opposite breast to match the reconstruction. Adjustments of the flap volume or scars can also be undertaken at this time. Patients may also elect to undergo nipple reconstruction.
If you had bilateral reconstruction, you may elect for a nipple reconstruction. Again scar revision or adjustments of volume to get better symmetry can also be undertaken at the second stage.

Can I travel in an airplane after surgery?

Yes it is safe to travel after having autologous breast reconstruction.
However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.
Also it is not wise to undertake a long haul flight shortly after a long procedure as it significantly increases your risk of a DVT (clot in the leg) or PE (clot in the lungs)

When will I be able to swim after my DIEP breast reconstruction?

You may do gentle swimming in a pool or beach after 2-3 weeks once all wounds have healed and all the drains are out. Heavier swimming (like doing laps) will need to be deferred for 3 months.

When will I be able to drive after breast reconstruction?

It is best to not drive for the first 1-2 weeks after mastectomy and reconstruction.

Will breast reconstruction change the sensation of my breasts?

Yes
You should expect that mastectomy surgery will render the breast skin (and nipple if it is kept) insensate, meaning that it will be numb and stay like this forever.
Some parts of the mastectomy skin do recover sensation slowly over 12 months or longer but this is very individual, and unpredictable.
The flap will usually remain insensate for life.

Can I breastfeed after breast reconstruction?

No, Since the breast tissue has been removed during mastectomy.

Will I need further imaging for ongoing monitoring of breast cancer after reconstruction?

In bilateral reconstruction, general no.
A mastectomy is more than 95% successful in removing breast tissue.
Because no or minimal breast tissue is left behind there is usually no further imaging required for breast cancer screening.
However you should discuss ongoing surveillance with your breast surgeon who is likely to see you on an ongoing basis for clinical examination and monitoring.
For unilateral (one sided) reconstruction, you should participate in regular screening for the opposite native breast.

Are there any alternatives to DIEP flap reconstruction?

Yes
Reconstruction can be achieved through implants or latissimus dorsi reconstruction.
Alternateively your own tissue can be taken from other sites such as the inner thighs – ead our section on TUG flaps to find out more.

Procedure Pricing

A quote for this procedure will be provided to you after a consultation with Dr. Aggarwal. You can also call or email our office for our current indicative pricing.
A Medicare item number usually applies to breast reconstruction surgery.
- You must confirm with your health fund that you are covered for the appropriate item numbers
- We cannot take responsibility for health funds rejecting claims for coverage of surgeon/anaesthetist or hospital fees.
The above fees include:
- Surgical fees (for 2 plastic surgeons, 1-2 assistants)
- Anaesthetist fees (including coverage for mastectomy part of the procedure)
- Hospital fees
- All Follow up
Please note that the above fees do not include
- Preoperative consultation fees
- Fees for the breast surgeon for mastectomies
- Future procedures such as opposite breast modification (breast lift/reduction), nipple reconstruction, fat grafting, etc
- Fees for CT angiogram

Public patients

It is possible to have your surgery through the public hospital
For immediate reconstruction you will first need to see a breast surgeon at RPA or POW if you wish to have Dr Aggarwal participate in your care. We are happy to provide you some suggestions if you are unsure of who to see.
Breast and plastic surgeons have limited public operating lists and will then coordinate a time for your surgery.
You should note that under Medicare or as a no gap patient (if insured) there are no out of pocket costs under this system.
In return for free health care, please note that:
- You may get limited say as to when your procedure may be scheduled
- May not have Dr Aggarwal oversee your care (as another plastic surgeon may provide cover if operating time cannot be coordinated)
- Your reconstruction will be performed by a plastic surgery registrar (under the supervision of Dr Aggarwal, or another plastic surgeon)
- Your follow up will be with the hospital in clinics with the registrars
- There is waiting list of 12 months for delayed breast reconstruction
- In case of any post operative issues or complications, you will need to contact the plastic surgery registrar on call at the hospital where your care was provided
Public patients coming to Dr Aggarwal’s private rooms are charged our normal initial and follow-up consult fees.

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