The Blog Dr. Karen Horton An Educator, Innovator and Mentor in the field of Plastic and Reconstructive Surgery.

Step-by-step DIEP flap & nipple-areola reconstruction

How do we make a new breast using tummy skin and fat?  The DIEP flap is a microsurgical transplant from one part of the body to another – in this instance, from the lower abdomen (ranging from the belly button upwards to where the pubic hair starts below) – to the chest in women who have had or who need a mastectomy for breast cancer.

You can learn more about DIEP flap breast reconstruction here.

The following case is an illustrative step-by-step pictorial example of how Plastic Surgery can create new form out of other tissues from the body.  Which is absolutely amazing (even to us, and we have done 500 cases)!

After bilateral mastectomies for breast cancer without reconstruction

This woman had previously undergone bilateral mastectomies for breast cancer.  Unfortunately, was never offered breast reconstruction (which breaks our heart!).  She did not require chemotherapy and radiation and she took it upon herself to learn about her reconstructive options.  She learned about the DIEP flap as an option through internet searches and was thrilled to come to San Francisco for her surgery.

After DIEP flap breast reconstructions. Scars are pink as expected for the first 3-6 months.

Her tummy skin and fat was microsurgically transplanted from her lower abdomen to her chest to reconstruct her breasts.  Bilateral DIEP flaps reconstructed her breasts to create new soft, warm, living tissue breasts that were her similar to her original breast size.

After nipple reconstructions. Her scars are beginning to fade.

Six months later, she underwent nipple reconstructions, abdominal scar revision and free fat grafting.  What is free fat grafting?  Learn all about it here.  We use fat grafting not only as a surgical tool to help fill in hollows or depressions around a flap or implant-based breast reconstruction, but as a way to further improve donor sites or other areas of the body.

Like all our patients, this woman greatly appreciated that liposuction could be used as a surgical tool to improve her final reconstruction outcome.  We encourage our patients to think about second stage surgery after their initial breast reconstruction as their “Mommy Makeover”, “breast cancer makeover”, “Nana Makeover” or any type of makeover that might be appropriate to name!

Areola circle marked before injection of local anesthesia for medical tattoo.

Next, medical tattoo was used to create an areolar circle as an in-office minor procedure, performed under local anesthesia.  Initially after tattoo, the area bleeds slightly.  This is because the medical tattoo pigment is pushed into the deep layer of skin called the dermis by small needles that oscillate over the skin.

Immediately after medical tattoo. Fine points of bleeding are called the “paprika sign”, indicating the pigment was correctly injected into the dermis by rapidly oscillating tattoo needles.

The fresh bleeding shows that the pigment is in the correct layer of the skin.  Inside the dermis, immune system cells called macrophages “eat” (phagocytose) the pigment and it becomes incorporated permanently in the dermis.

One month after areola tattoo. The color is still bright.

At one month after tattoo, it is still bright and has not yet begun to fade.  It will gradually fade over years (like regular tattoos).  The brightness of the color becomes more normal and natural over time.  Areola tattoo can always be touched up later in the office if needed (in 5-10 years).  See other examples of nipple and areola reconstruction here.

Three years after DIEP flap reconstruction and nipple and areola reconstruction. The tattoo has faded to a more normal color. It can be touched up as needed in the office in 5-10 years as needed.

3 years later, her tattoo has faded and her nipple reconstruction has flattened slightly.  Her scars are mature and she has successfully moved forward with her life, no longer being reminded that she is a breast cancer survivor every time she changes her clothes or puts on a swim suit.

Her before and after images speak for themselves!  Her full profile can be seen in our DIEP flap before and after gallery.





This patient shows us how incredible reconstructive microsurgery is, how recreation of the breast form and nipple-areola complex can complete a woman and why we are so proud to offer this incredible surgery to women!

To learn more about DIEP flap breast reconstruction, free fat grafting or nipple areola reconstruction, visit our website or call 415-923-3067 to schedule an appointment.

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