DIEP and SIEA Flap

The Latest Advances in Microsurgical Techniques

DIEP/SIEA Flap Breast Reconstruction

The plastic surgeons of the New York Breast Reconstruction Associates at Aesthetic Plastic Surgery, PC, perform hundreds of microsurgical free flap breast reconstruction operations every year. The DIEP (deep inferior epigastric perforator), SIEA (superficial inferior epigastric artery) and TRAM (transverse rectus abdominus myocutaneous) free flap procedures provide numerous benefits when compared to implant breast reconstruction and the standard pedicled TRAM flap breast reconstruction. If you are considering post-mastectomy reconstruction, we can discuss these options in detail with you during an initial consultation. This will allow you to decide which treatment is best suited to meet your needs. To arrange a meeting with one of our reconstructive surgeons, please contact us today.

DIEP Flap Procedure

This technique involves removing a portion of skin and fat from the lower abdomen, which is then transferred as a free flap to the chest wall. However, unlike the pedicled TRAM flap technique, the DIEP flap procedure does not require elevating and moving the rectus abdominus muscle in order to provide blood supply to the flap. Instead, the blood supply is provided by deep inferior epigastric perforator vessels, which are dissected out through incisions made in the rectus muscle. Prior to surgery, a CT angiogram can help confirm the presence of sufficient perforator vessels providing blood supply to the lower abdominal wall. While the CT angiogram can map out these vessels, the actual availability of vessels and the number of perforators necessary to support the new DIEP flap are determined during surgery.

After the flap has been raised, it is transferred as a free flap to the mastectomy site on the chest wall, and the blood vessels – donor and recipient – are matched up using microsurgical technique with an operating microscope. The DIEP flap tissue is then formed to create a breast shape.

DIEP Microvascular Free Flap

Illustration © BRO Development, LLC. All Rights Reserved. www.breastreconstruction.org

SIEA Flap Procedure

The SIEA flap technique is similar in many ways to DIEP flap reconstruction in that the lower abdominal tissue is transferred as a free flap for the purpose of breast reconstruction. Unlike the DIEP flap technique, which requires making incisions in the rectus muscle in order to access perforator vessels, different vessels are used in SIEA flap reconstruction such that the muscle can be left intact. Instead, the superficial inferior epigastric vessels provide the blood supply in an SIEA flap. When exposing these superficial vessels, incisions are made in the lower abdominal skin and fat only.

Once the SIEA flap is fully elevated, it is then transferred to the chest wall as a free flap, where its blood supply is connected to the recipient blood vessels under an operating microscope. Once this process is complete, the tissue is used to create a breast shape. Post-operative pain is potentially reduced with this technique since incisions in muscle are minimized or avoided. Most patients are not candidates for the SIEA flap since only individuals with large caliber superficial inferior epigastric vessels can have this procedure. Sometimes, the CT angiogram can predict the availability of these vessels pre-operatively.

Illustration © BRO Development, LLC. All Rights Reserved. www.breastreconstruction.org

TRAM Free Flap Procedure

Like the DIEP and SIEA flap techniques, the TRAM free flap procedure uses the lower abdominal skin and fat, which is transferred as a free flap to reconstruct the breast after mastectomy. The difference is that in the TRAM free flap, the perforator blood vessels to the flap are included within a small portion of the rectus abdominus muscle. Compared to DIEP and SIEA flaps, since some muscle is taken with the TRAM free flap, the risk of hernia is slightly higher. Compared to the pedicled TRAM flap, more tissue can be safely transferred with the TRAM free flap approach since the flap blood supply is better. Also, since only part of the rectus muscle is used in the TRAM free flap, the risk of hernia is less that the risk in patients following pedicled TRAM flap harvest.

Pre-operative CT angiography can potentially help determine if patients are candidates for the TRAM free flap as an alternative to the DIEP or SIEA flap approach. During surgery, the decision is made regarding the width of rectus muscle required for preservation of flap blood supply prior to flap transfer. After flap transfer, the small abdominal wall muscle defect that remains at the donor site may require repair with a patch of mesh.

Illustration © BRO Development, LLC. All Rights Reserved. www.breastreconstruction.org

Risks and Benefits

As with any surgery, there are risks associated with DIEP, SIEA and TRAM free flap breast reconstruction. However, our team of surgeons takes every precaution to mitigate these risks and has a track record of providing superior, natural-looking results for our patients. Although DIEP, SIEA and TRAM free flap reconstruction can take longer than the alternative pedicled TRAM methodology, a comparative benefit of these methodologies is that post-surgery recovery tends to be easier. Similarly, there is a lower risk of donor site problems such as hernia or bulging. Since these flaps are microsurgical free flaps, there is a very small risk of total flap loss due to problems with flap blood supply. For this reason, flap vascularity is carefully monitored during the patient’s hospital stay.


A number of factors will contribute to your candidacy for DIEP, SIEA or TRAM free flap breast reconstruction – Do you desire autogenous tissue reconstruction? Are you a poor candidate for implant reconstruction? Have you previously undergone radiation treatment? Among the most important factors will be the amount of skin and fat available along the lower abdominal wall. Women who have previously undergone abdominal surgery or those with insufficient abdominal wall tissue may not be candidates for this type of procedure. In such cases, alternative techniques such as TUG flap reconstruction may be called upon.

Contact the Plastic Surgeons of the
New York Breast Reconstruction Associates at Aesthetic Plastic Surgery, PC

Please contact our Long Island, New York plastic surgery practice today if you are considering post-mastectomy reconstruction. Our surgeons have performed thousands of breast reconstruction procedures and are committed to providing superior, natural results for our patients.


Aesthetic Plastic Surgery, PC Great Neck Office 833 Northern Blvd
Ste 160

Great Neck, NY 11021
(516) 498-8400

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