Breast Reconstruction

Deep Inferior Epigastric Artery Perforator Flap

A Deep Inferior Epigastric Artery Perforator (DIEP) flap is a perforator free flap of lower abdominal skin and fat that is supplied by the deep inferior epigastric artery (Figure 2). In this flap, the rectus muscle and anterior sheath are preserved, providing a first-line autologous option for immediate or delayed reconstruction in patients. It is often seen as the gold standard for breast reconstruction and a good option for those who are unsuitable or wish to avoid implants.

DIEP flap elevation typically begins with skin and subcutaneous tissue dissection down to the anterior rectus sheath, identifying perforators that pierce through the fascia. The perforators are then traced through the rectus muscle (intramuscularly). The deep inferior epigastric vessels are dissected to obtain adequate pedicle length. The pedicle is freed from the muscle and the flap is harvested. The flap is detached and transferred to the recipient site for microsurgical anastomosis. The donor site is closed, often with reinforcement of the abdominal wall to reduce hernia risk.

A CT angiogram is required pre-operatively to identify perforator number, their calibre and course, and identify any secondary superficial inferior epigastric artery (SIEA) options. The main complications from a DIEP flap include venous congestion, fat necrosis, partial flap loss, donor site hernia (less common than TRAM), and abdominal wound surgical site infection.

By TeachMeSeries Ltd (2026)

Figure 2
The deep inferior epigastric artery (DIEA) arises from the external iliac artery just above the inguinal ligament, supplying the anterior abdominal wall muscles

Superficial Inferior Epigastric Artery Flap

The superficial inferior epigastric artery (SIEA) flap is a lower-abdominal free flap that leverages the superficial vascular system, offering an attractive alternative to DIEP when the superficial vessels are well developed and in cases where intramuscular perforator dissection is to be avoided.

As it avoids the rectus muscle and any fascial breach, it can preserve abdominal wall strength and reduce donor-site morbidity. Further benefits occur with a shorter operative time and also leaves the deep inferior epigastric system untouched for future reconstruction options. However, it is limited by the variable presence and calibre of the SIEA, which is absent or inadequate in a majority of patients, and by a smaller skin-fat paddle, restricting its use for larger reconstructions.

Transverse Rectus Abdominis Myocutaneous Flap

The Transverse Rectus Abdominis Myocutaneous (TRAM) flap uses the same lower-abdominal skin fat paddle as a DIEP, but includes varying amounts of rectus muscle and anterior sheath (Figure 3). It can be raised as a pedicled or as a free flap when perforators are poor, when operative time is limited, or where microsurgical perforator dissection is not feasible.

Its advantages in large-volume reconstruction and in salvage after failed perforator flap. However, its main it is associated with higher donor-site morbidity than DIEP, due to disruption of the sheath hernia and flap fat necrosis if perfusion is marginal.

Blausen.com (2014). WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436., CC BY 3.0, via WikiMedia Commons

Figure 3
Schematic demonstrating the anatomy of a TRAM flap

Latissimus Dorsi Flap

A Latissimus Dorsi (LD) flap is a myocutaneous flap based on the thoracodorsal system. It can be used in conjunction with an implant for moderate-to-large breasts, as an autologous salvage in irradiated fields, or when there is abdominal morbidity.

The LD flap is a pedicled myocutaneous flap supplied by the thoracodorsal artery and veins, along with branches of the subscapular system within the axilla. As the flap remains pedicled, microvascular anastomoses are not routinely required.

The flap is raised through an incision along the posterior axillary fold, to access the muscle and its vascular pedicle. The muscle is elevated from the chest wall in a deep plane (Figure 4), dividing minor perforators as needed. Care is taken to preserve important nerves, specifically with the thoracodorsal nerve either maintained or divided depending on reconstructive aims. The long thoracic nerve lies on the chest wall along serratus anterior and should be protected to avoid scapular winging. A sufficiently wide axillary tunnel must be ensured into the breast pocket to avoid pedicle compression and ensure reliable perfusion.

The main complications of LD flap includes insufficient volume (especially if used without an implant), donor-site seroma, and shoulder dysfunction.

By TeachMeSeries Ltd (2026)

Figure 4
The latissimus dorsi muscle is large triangular muscle in the lower back, covering most of the posterior trunk

Implants

Implants are saline or silicone-based devices that can be placed subpectoral (submuscular), pre-pectoral (subglandular), or in a dual-plane for breast reconstruction. Implant-based reconstruction can be performed as a single-stage procedure or as a two-stage expander-to-implant pathway. They suit patients who prefer a shorter operation and recovery, who lack sufficient donor tissue, or in whom symmetry procedures are planned.

The implant can be positioned with subpectoral placement with careful recreation of the inframammary fold, whilst pre-pectoral placement placement can be used according to soft-tissue quality and preference. In borderline soft tissue, combining an LD flap with an implant improves coverage and lowers implant exposure risk.

The main complications associated with the procedure are infection, capsular contracture, capsule rupture, or malposition.

Adobe Stock, licensed to TeachMeSeries Ltd

Figure 5
Schematic demonstrating the anatomical placement of an implant

Nipple-Areola Reconstruction

Nipple-areolar reconstruction is usually staged once the breast mound has settled (often ≥6months) to permit accurate placement. Options include local flaps, nipple sharing from the contralateral breast, areolar tattooing (Figure 6), or full-thickness skin grafts with pigmentation match. Counselling should cover expected loss of projection over time and the potential need for tattoo top-ups.

SamanthaCham, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Figure 6
Right breast post-areolar micropigmentation