Prior to the surgery, either the night before, or the day of, Dr. Keller will marked on the patient the flap and the location of the perforating blood vessels. The flap extends across the entire lower abdomen, from one hip to the other. The scar is well below the level of the belly button but, is not quite as low as the usual tummy tuck incision. The perforating blood vessels are found by listening for them with a Doppler probe. The Doppler is really just a fancy stethoscope and this exam is not painful.

The breast is also marked either for the mastectomy with the smallest possible excision of skin if the mastectomy is to be done at the same time, or for the breast reconstruction if this is a delayed reconstruction.

Special gel cushions (to protect the patient) are placed on the operating table prior to putting the patient on the table. The surgical procedure is long because of the multiple demanding and exact steps. No body cavity is entered during the surgery and this keeps the risk small. (This is not abdominal nor open chest surgery.)

If a mastectomy is being done, a general surgeon, and not Dr. Keller, will complete this portion of the procedure. Because of Dr. Keller's background and training in general surgery, the breast surgeons that he works with allow him to  design the incision for the mastectomy. If for some reason, the general surgeon does not feel comfortable with the design or the amount of skin to be removed, that person is encouraged to make whatever incision is necessary to cure the patient of the cancer.

One of the first parts of the surgery that Dr. Keller will perform is the identification of suitable blood vessels in the chest to supply the DIEP flap after the transfer. The initial part of this dissection is done with high power loupe magnification. The final stages of blood vessel preparation are done under the operating microscope. These blood vessels range from 1.6 to 3.0 mm in diameter. They are extremely delicate and are handled like wet tissue paper.

The other half of the surgery involves the dissection and isolation of the DIEP flap.  Dissection is begun laterally and continued medially until the first perforators are identified. As few as one and as many as five suitable perforators are chosen for the transfer. The grizzle or fascia around the base of these perforating blood vessels is cut. With the aid of loupe magnification and occasionally the operating microscope the perforating blood vessels are traced through the rectus muscle down to the common deep inferior epigastric vessels. With this dissection, the flap is isolated on only its vascular pedicle. The pedicle is now divided and the flap is placed on the chest.  Under the operating microscope the vascular pedicle is connected to the recipient blood vessels in the chest. This restores the blood flow to the DIEP flap.

The flap is now loosely secured to the chest and attention is directed at closing the abdomen. The opened fascia is closed. No synthetic mesh is used because the muscle is left intact. The belly button is freed of skin attachments but is left attached to the abdominal wall. The remaining abdominal skin and fat is freed to the lower rib border. This skin and fat is then pull down like a large window shade to the lower border of the abdominal wound.  This is facilitated by flexing the operating room table at the patient's waist level. The wound is then repaired and a new hole made in the abdominal skin for the belly button.  The location of the belly button is correct because it was never moved. Only the skin around the belly button was repositioned.

The final step is contouring the flap, securing it to the chest wall, and making it into a breast. During the course of the surgery, Dr. Keller will instruct the anesthesiologist to change the patient's position on the operating room table in order to facilitate and optimize the shaping of the breast.  During the final stages of the contouring of the breast, the patient is in a semi sitting position. A more naturally shaped breast can be reconstructed with the patient in an upright position.  Care during this portion of the procedure is taken to not have the weight of the flap pull on the vascular pedicle.

At the conclusion of the surgery, Vaseline gauze dressing is placed on both the reconstructed breast and the abdomen. No tape is utilized there by avoiding tape burns caused by removal of the dressing.

This was written as an overview of DIEP flap breast reconstruction and must not be utilized as a manual for performing this procedure. Only with proper training and supervision should a surgeon undertake to perform DIEP flap breast reconstruction.