What is Phase 2 DIEP Flap Surgery & Is It Always Necessary?

If you’re contemplating undergoing DIEP flap surgery as your breast reconstruction choice, or if you’ve already completed phase 1 of DIEP flap surgery, you might be mulling over what to do about phase 2, or wondering if it’s needed at all.

In this post, we’ll talk about all this. But first, a reminder that this blog is never a substitute for medical advice from professionals. I share about my experience with DIEP to help inform anyone interested and to reassure others who are thinking about this option. That’s my hope and intention anyway.

I completed DIEP flap phase 1 surgery in July 2020, smack dab in the height of the pandemic no less. I completed phase 2 a year later in August 2021. Yep. Pandemic still very much raging. The pandemic definitely added another layer of stress, but I decided to proceed both times nonetheless.

You might want to read, Preparing for surgery during a pandemic.

You might also wish to read, What’s it like six months post DIEP flap surgery? and/or, What’s it like one year post DIEP?

So, is phase 2 DIEP flap surgery always necessary?

Short answer, no. Long answer, keep reading.

The decision to undergo phase 2 is a personal choice. My plastic surgeon stated more than once that she would never tell a patient she had to have more surgery. So, if your PS says you must have a phase 2, this is not the case. It’s up to you. I would even suggest that any such sort of insistence is a red flag indicating you might need another opinion and/or surgeon.

This is yet one more reason to discuss phase 2 before having phase 1. You and your surgeon need to be on the same page from the start.

Having said this, it is typical for there to be a phase 2, also sometimes referred to as second stage DIEP flap surgery or revision surgery. Sometimes, there can be more than 2 stages. Everyone’s situation is different, so there’s no one-size fits all here either.

Why have phase 2 DIEP?

The purpose of phase 2 is to fine-tune things — meaning the breasts and the scar areas.

Is DIEP phase 2 covered by insurance?

The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. DIEP phase 2 should be covered, as well as phase 1, of course.

Update: Don’t assume you’re covered. There have been coding changes. Insurers have been trying to eliminate coverage for DIEP. Read more here and do your own research. Can’t stress this enough.

You might run into issues with Medicare and/or Medicaid coverage which can vary state to state. I’ve been having an issue getting a portion of mine covered, so just a heads up. Phase 2 is not cosmetic surgery, though procedures might be used that are also sometimes used in cosmetic surgery. It is still breast reconstruction surgery and should be covered as such. Again, get all this clarified before surgery for peace of mind.

Learn more here and here.

Update: I had to appeal and not just once but twice. You might want to read: When Medicare denies your claim — 9 tips for a successful appeal.

What’s involved in phase 2?

During phase 2, symmetry of your breasts can be addressed. If one breast is larger than the other, this can be addressed with either fat grafting from another area of the body to add volume to the smaller one. Or, as was the case with me, liposuction can be preformed to make the larger breast smaller.

Phase 2 is also the time when scar revision is done. There might be need for this on or around the reconstructed breast(s) or at the donor site (abdomen). Sometimes, the initial scarring can be smoothed out a bit or fine tuned to minimize appearance and roughness as much as possible.

To be clear, significant scars will remain.

Some women have a unilateral (one side) mastectomy and, therefore, need “only” unilateral DIEP flap surgery as well. In this situation, during phase 2, the natural breast can be made larger or smaller in order to achieve better symmetry.

If you’re opting to do nipple reconstruction, this can usually be done during phase 2 as well. I did not opt for this during my phase 2.

I did have nipple reconstruction with my implants years ago.

You can read about that here.

The reason I opted out of nipple reconstruction this time around was because I wasn’t satisfied with how that all turned out the first time. Actually, the nipples turned out okay, they just didn’t last. My reconstructed nipples flattened out, or were reabsorbed, after a couple years. And not evenly on both sides, I might add.

So, if you’re going this route, be sure to get all this clarified as far as what to expect.

This time, I am mulling over doing 3D tattooing only. I had areola tattooing done with implants, too.

You can read about that here. (I know, I know. It’s a never-ending saga.)

So, breast reconstruction is not a quick or easy fix, no matter which route you choose.

And, let’s not forget that opting out of reconstruction and choosing aesthetic flat closure is an option that makes total sense for many women. This option, of course, presents challenges of its own.

No matter what a woman chooses, a mastectomy is a huge deal and represents a huge loss in more ways than one.

No, breasts do not define us, but they sure as heck are (or were) part of us and for many years too. Loss of this sort requires grieving too.

You might want to read, Things We Aren’t Supposed to Say About Mastectomies, Reconstruction & Breasts.

and/or Breast Cancer Is a String of Losses.

When is phase 2 done?

Phase 2 is usually done at least three months post-phase 1, although you can certainly wait longer. I did. There does need to be adequate time post-phase 1 for healing. Three months is generally the standard minimum wait between phases.

How long does phase 2 surgery take?

Again, every situation is unique, but generally, phase 2 is done on an out-patient basis and typically takes two-three hours, depending on what you’re having done.

What was my phase 2 experience like?

Again, this is my experience. Yours might be different.

Both my phase 1 and phase 2 surgeries were done at Mayo Clinic in Rochester, MN, so it involved a two-three hour drive. Dear Hubby and I decided to get there the night before (both times) and try to get some sleep before surgery day.

• The night before surgery, you’ll likely need to do the pre-surgery shower scrub of your neck, chest and abdomen using that gross, orange disinfectant soap — and then again in the morning.
• Upon arrival at the hospital, you’ll do the usual pre-op check-in stuff.
• Surgery itself will go quickly this time compared to phase 1 — nice for the person accompanying you.
• After time in recovery and going over discharge instructions, you’re outa there!
• Sort of. We were advised to stay at the motel another night — just in case. We were happy to oblige.
• Once home, you can relax and start healing.
• I did not have drains (woohoo!), but it is possible you might.
• You’ll be advised to start and keep moving around right away, but of course, it’s imperative to follow directions from YOUR doctor. I started taking daily walks right away, though shorter ones. If you over do things, you have an increased chance of excess swelling and possibly other problems. So, don’t do that. Don’t over-do it!

What about pain?

It might sound surprising, but I actually had more discomfort following phase 2. It wasn’t pain so much, but rather, it was soreness I experienced, probably due to liposuction.

And yeah, I was super fortunate to experience no pain after phase 1. Even my medical team couldn’t believe it and still talks about it whenever I go for follow-ups. In addition to no pain, I also did not walk hunched over at all. Nope. Not at all.

I’d like to think this was due to me being in excellent shape and being completely prepared mentally, but I know better. It was likely due to plain old good luck and having a highly skilled team of professionals.

I mention this because like you perhaps, I went into both surgeries expecting the worst and the worst didn’t happen. Not for me anyway.

And yes, you bet I was/am grateful.

Phase 2 discomfort was completely handled with Tylenol. (As was phase 1 in my case.)

What about bruising?

Apparently, my body doesn’t like liposuction much as I had significant bruising. Since I had liposuction on both sides in the breast and scar areas as well as in the abdominal scar area, I had quite a lot of bruising. Not gonna lie, it was startling. Even my medical team was a bit shocked by the amount of bruising I had.

It may or may not be important to note that I’m a person who has always bruised easily for whatever reasons. Bruising was on both sides, by the way.

Bruising resolved on its own, but it took a few weeks.

So, be prepared for bruising with phase 2. And be patient.

I can’t even believe I’m sharing this photo, but you know, #keepingitreal. Similar bruising at abdominal scar, but thought I’d spare you.

What about follow-ups and photo shoots?

I had my first follow-up at about 10 days. So expect something similar. There were similar follow-ups periodically over a period of months. In fact, I had my last (I hope) follow-up late January of this year.

So again, patience, patience, and more patience!

And yes, at every follow-up there have been those photo shoots we all love. Not!

Honest to God, if I didn’t want to help other women contemplating DIEP and physicians learning and honing their skills for this stuff, I would refuse the photo sessions. I hate them that much. But, I do care about helping to inform/educate others, so…

Other tidbits of advice

• Recovering from any surgery requires time and rest. So take frequent naps/rest breaks — no guilt allowed!
• I was told I could sleep in any position I was comfortable in. Your doctor might say otherwise.
• Showers were allowed right away. Yay! Again, your doctor might say something different.
• Eat healthy meals and drink lots of water.
• Resume normal exercise and other activities as directed. Again, don’t over-do it.

Final thoughts about things you should know

As with every breast cancer related surgery/procedure, the more you know going in, the better. Get all your questions and concerns addressed beforehand. And at follow-ups, of course.

Prepare your healing environment ahead of time too. (Separate post on this coming.)

Before phase 2, it’s imperative that you and your surgeon be on the same page as far as what you want done and what to expect. I can’t stress this enough.

Sometimes, it’s hard for plastic surgeons to fully understand our perspectives, what’s bugging us about surgery outcomes or what we really want. They aren’t mind readers!

You might want to read, Dear Plastic Surgeons, 14 things we want you to understand.

So, be clear about what you want and expect. Don’t beat around the bush or be embarrassed to ask anything that’s on your mind. Believe me, they’ve heard and seen it all. They just likely haven’t personally experienced this stuff. Again, be clear about expectations. And realistic, too, of course.

After all, this is your life. Your body. Your surgery. So, you gotta speak up and self-advocate.

That shared-decision making thing — it’s vital here too.

Remember, your body is remarkable in how it heals. It’s something I marvel at still.

YOU are remarkable.

I hope my explanation of phase 2 and reading about my experience helps you (or someone you know) with yours (theirs).

If you have questions or tips to add, be sure to leave them in the comment section below.

I probably missed some things. If I think of any, I’ll add them, so you might want to stop by again if DIEP phase 2 is in your future.

Good luck, if it is.

This, too, you can do!

Thank you for reading and sharing this post!

Have you visited the Nancy’s Point FREE Resource Library yet?

Have you had DIEP flap phase 2 surgery and if so, do you have a tip to add?

Do you have a question about DIEP flap phase 2 (or phase 1) surgery?

Have you chosen a different breast reconstruction option (including aesthetic flat closure)?

Have you had DIEP flap phase 1 and opted out of phase 2?

Learn more about DIEP flap surgery via PRMA Plastic Surgery, DiepCjourney, and Breast Advocate^® (App).

A NOTE FROM NANCY: I write about the peculiar twinship between my DIEP flap surgeries and the pandemic in my new book, EMERGING. Order it in print or for Kindle at Amazon. EMERGING is also available at most online booksellers such as: BAM, Bookshop.org, Barnes & Noble, and more.