DIEP Flap Offers Breast Reconstruction Without Implants

Kathy Attieh, 49, wasn’t prepared for her diagnosis of stage 2 breast cancer when she received the results of her mammogram, MRI and then biopsy in 2023. Following consultation with Lehigh Valley Topper Cancer Institute experts as part of its multidisciplinary clinic (MDC), the Nazareth resident was equally unprepared for the prospect of a double mastectomy (having both breasts surgically removed).

However, one thing Attieh was certain about: When it came to reconstruction, she didn’t want breast implants. “Friends have had complications with them,” she says, “and sometimes they just look unnatural.”

She felt relieved when she met Nathan Miller, MD, Associate Chief, Division of Plastic Surgery, with Lehigh Valley Institute for Surgical Excellence. He introduced Attieh to deep inferior epigastric perforator artery (DIEP) flap reconstruction, an alternative to breast implants. It’s a surgical technique that uses the patient’s own blood vessels, fat and skin to rebuild the breast, and it’s offered at Lehigh Valley Health Network (LVHN).

A divorced mother of two boys, Attieh was in the middle of touring colleges with her older son when she received her breast cancer diagnosis. Her first step with the Cancer Institute was chemotherapy because of the aggressiveness of her cancer. Surgery was next. She and her team felt a double mastectomy would be the best choice for her.  

“The area on her MRI was large; 5.2 centimeters,” says Heiwon Chung, MD, Chief, Section of Surgical Oncology, with the Cancer Institute. “We always have an option to do a lumpectomy, where a smaller portion of the breast is taken depending on whether we can obtain adequate margins. Because of Kathy’s family history and aggressiveness and size of the tumor, she decided to go with bigger surgery [double mastectomy, both breasts] rather than small surgery [lumpectomy].” 

Both chemotherapy and the prospect of losing both breasts dealt a heavy blow to Attieh’s energy level and self-esteem. “I had 18 weeks of very hard chemo with a port,” Attieh says. “I was determined not to let it interfere with my son’s senior year. But you lose all your strength. We went to beach with friends, and I couldn’t even carry a beach chair.”

When Attieh got home, her hair – which had always been long and lush – came out in clumps. She even lost her eyelashes. “I’m a girly girl. I love going out and dressing up,” Attieh says. “It felt like my femininity was ripped away.” In conjunction with her treatment, the Cancer Institute staff helped connect Attieh with counselors who talked her through her feelings.  

After chemotherapy, Attieh met with Dr. Miller and called that meeting, “her first spark of hope.” He went over all the options, one of which was the DIEP flap.  

In DIEP flap reconstruction, the breast surgeon conducts the mastectomy but leaves the breast skin, the nipple and areola. “We use the majority of the breast skin that’s left after the mastectomy, and only a minimal amount of abdominal skin, if necessary,” Dr. Miller says, noting that no muscle is taken from the abdomen, so side effects are minimized. “Using microsurgery, we connect blood vessels in the chest to the blood vessels attached to the tissue from the lower abdomen so there is immediate blood flow to the flap tissue.”

While recovery is slightly longer, Dr. Miller points out the DIEP flap’s advantage: “You’re getting a tummy tuck at the same time you’re getting reconstructed breasts,” he says. He adds there are limitations as to who can undergo the surgery. They include those who have had abdominal wall hernias, as well as those who are thin without excess lower abdominal tissue.

Even though many people can be candidates, the procedure is often not discussed as an option. “It’s important to ask your reconstructive surgeon if they have additional training in microsurgery to ensure you are informed about all the reconstructive options,” Dr. Miller says. “Fortunately, our team is highly trained, and we’ve been conducting DIEP flap procedures for years.”  

For Attieh, recovery included two weeks of doing nothing. Then she slowly eased herself back into her life. On Dr. Miller’s referral, she attended post-mastectomy physical therapy, which promotes energy endurance and aids lymphatic drainage, minimizing risk of long-term swelling.

According to Attieh and her clinical team, everything went well. “I have a flat stomach, a pretty belly button, beautiful natural-shaped breasts and my own nipples,” she says. “I have 100 percent of my femininity back.” The breast cancer survivor is especially appreciative of the care she received at the Cancer Institute.

“LVHN goes above and beyond. I would get random calls from the staff just checking in to see how my day was going,” she says. “What got me through was knowing I had a whole team behind me.”

Today, Attieh is walking her beloved dog, Luna, and taking hikes with her, which she missed terribly while she was recovering. “I’m getting my strength back. I feel like they built me back stronger,” she says. “And I couldn’t be happier with my reconstructed, new breasts. The new ones are more appealing and natural looking.”