Failed DIEP Flap? Alternative Flap Options to Consider for Breast Reconstruction

DIEP Flap failures aren’t common but can happen. If your DIEP fails, know that you have options for reconstruction that don’t compromise muscle. Your plastic surgeon may not be skilled in these options, but it’s worth getting multiple opinions. Note that some women will replace a failed flap with an implant.

If you’re interested in an alternative flap, review the list below for alternative flaps that don’t compromise the muscle. This outlines top alternative flaps, but review this list of autologous reconstruction flaps for additional information. Surgical groups are listed below each flap option, note that this is not a comprehensive list of surgeons offering each alternative flap but this is a great starting place for getting multiple opinions to make an informed decision.

Alternative Flaps to DIEP if Your Flap Fails

SGAP Flap

SGAP (superior gluteal artery perforator) is an alternative donor site that transfers blood vessels from the upper buttock for reconstruction. SGAP does not compromise the muscle and full strength is preserved. This is not a widely performed flap across the United States and if looking to travel for surgery out-of-network, it is worth looking into a Single Case Agreement to be treated in-network.

Surgical Groups to Research Offering SGAP

• Center for Restorative Breast Surgery – offers free remote consults. Dr. Sullivan at the Center for Restorative Breast Surgery pioneered the SGAP technique. Location: New Orleans, Louisiana
• Grand Valley Plastic Surgery (Dr. Henderson) – Offers out-of-state remote consults. Location: Grand Junction, CO
• Midwest Breast & Aesthetic Surgery – offers remote consults for out-of-state patients. Location: Gahanna, Ohio

TDAP/TAP Flap

A TDAP (also called TAP) flap stands for Thoracodorsal Artery Perforator. The TDAP/TAP flap preserves the muscle and strength of the patient. This donor site is an improvement over the Latissimus Flap (which takes muscle) and can be used as an alternative donor site if you have extra fat along your bra line.

Surgical Groups to Research Offering TDAP/TAP

• Center for Restorative Breast Surgery – offers free remote consults Location: New Orleans, Louisiana
• Grand Valley Plastic Surgery (Dr. Henderson) – Offers out-of-state remote consults Location: Grand Junction, CO
• Center for Breast Reconstruction – offers an educational call Location: New York, NY
• The Plastic & Reconstructive Surgery Group – remote consults depend on how far away the patient is and the doctor’s schedule. Locations: Greenwich, CT and Poughkeepsie, NY
• Zampell Plastic Surgery – also offers ICAP flap Location: Beverly Hills, CA

PAP Flap

PAP flaps (Profunda Artery Perforator) use tissue and blood vessels from a patient’s thigh to reconstruct the breast. The scar/incision may vary significantly by surgeon; it is important to get multiple opinions. This procedure preserves the muscle but the Center for Restorative Breast Surgery mentions on their SGAP page that a PAP may cut through sensory nerves (posterior femoral cutaneous nerve). It is important to ask your prospective surgeons about the risks involved. Some surgeons offer stacked PAP flaps using both thighs for one breast reconstruction.

Surgical Groups to Research Offering PAP Flaps

• The Institute for Advanced Breast Reconstruction – offers remote consults Locations: Santa Monica, CA, Thousand Oaks, CA, and Austin, TX
• Center for Breast Reconstruction – offers an educational call Location: New York, NY
• Breast Southwest & Aesthetics – offers virtual appointments Locations: Phoenix, AZ, and Chandler, AZ
• Nicholas T. Haddock, MD – Does not offer out-of-state telehealth visits, but does offer telehealth visits if you’re located in Texas. Location: Dallas/Ft. Worth, TX
• Grand Valley Plastic Surgery (Dr. Henderson) – Offers out-of-state remote consults Location: Grand Junction, CO

LAP Flap

LAP flaps (Lumbar Artery Perforator) use tissue from the lower back and love handle area. A commentary by Dr. Frank DellaCroce mentions it is a difficult but viable option in breast reconstruction and tends to be a flap of last resort due to its difficulty and short pedicle. LAP flaps preserve the muscle.

Surgical Groups to Research Offering LAP Flaps

• Breast Southwest & Aesthetics – offers virtual appointments Locations: Phoenix, AZ, and Chandler, AZ
• The Plastic & Reconstructive Surgery Group – remote consults depend on how far away the patient is and the doctor’s schedule. Locations: Greenwich, CT and Poughkeepsie, NY

Tips When Consulting with Different Surgical Groups

Remember that surgeons have their specialties. If a surgeon is only offering to take muscle such as a latissimus flap to reconstruct, that there are other options that don’t compromise the muscle and it’s worth it to get multiple opinions to make an informed decision.

Questions to ask

• Based on my body type, what is the recommended flap?
• How many of {insert flap name} do you do per year?
• What is your success rate?
• Where would the incisions be?
• Do you work with a co-surgeon?
• How long would the surgery be?
• How long would I need to stay in town (if traveling for surgery)?
• Is there free or discounted logging available (For example: Hope Lodge is free, funded by the American Cancer Society located in New Orleans). This is a full list of Hope Lodges available in the US which is offered to women undergoing surgery that was due to breast cancer (or risk of breast cancer) and is offered for revision surgeries.
• What are the risks involved with this surgery?
• Would muscle or sensory nerves be compromised with this surgery?
• What is the timeline for this surgery?
• Do you offer a stacked flap of {insert flap} you’re asking for?
• Ask to see before/after photos
• Talk to billing and find out if your insurance is in-network. If you have a narrow plan like HMO/EPO ask if there’s an option for a Single Case Agreement as a one-time agreement to be treated in-network due to a network inadequacy.

Create a spreadsheet, and record your answers from multiple practices/surgeons. If your DIEP flap failed, know you have other options that don’t take muscle if you don’t want implants.