Elective Removal of Bilateral DIEP Free Flaps for Gender Affirmation: A Case Report and Literature Review

Document Type

Conference Proceeding

Publication Date

9-2026

Publication Title

Plastic and Reconstructive Surgery. Global Open

Abstract

Problem Addressed: Traditionally, breast reconstruction options follow three pathways: no reconstruction, prosthetic based reconstruction, or autologous based reconstruction. While microvascular techniques have matured to the point that over 10,000 Deep Inferior Epigastric Perforator (DIEP) flap reconstructions are performed annually, there is a significant paucity of data regarding the elective removal of these healthy, integrated flaps. Although gender-affirming “top surgery” is frequently performed by general surgery, cases involving prior autologous microvascular free flaps are best addressed by plastic surgery due to the theoretical risks of pedicle retraction and internal thoracic bleeding. This case highlights the unique surgical considerations required to safely transition a patient from complex autologous reconstruction to a masculine chest contour.

Techniques: The patient is a 55-year-old non-binary individual with a history of bilateral total mastectomies in 2011, which was complicated by tissue expander failure due to infection. The patient was salvaged with bilateral DIEP free flaps in 2012 and subsequently underwent nipple reconstruction in 2013. After more than a decade of stable reconstruction, the patient elected for flap removal to achieve a masculine contour as part of gender-affirming care. Over 10 years after finalizing breast reconstruction, the integrated DIEP flaps were elevated, and the vascular pedicles—the deep inferior epigastric artery and vein—were meticulously identified, clipped, and transected at the chest wall. To ensure an aesthetic flat closure, approximately 20 cm of excess skin was excised bilaterally, with incisions placed along the inframammary fold. Comprehensive clinical photography is included, documenting the preoperative appearance, intraoperative pedicle identification and clipping, and postoperative outcomes.

Outcomes: Literature searches reveal no current publications discussing the removal of healthy, integrated DIEP flaps for gender-affirming care. This surgical intervention demonstrated the robust physiology and healing of a free flap, providing clear evidence of revascularization and angiogenesis. By performing a controlled takedown of the pedicle, the procedure achieved a safe, masculine contour without intraoperative complications. The patient remained stable with excellent results at the 3-month postoperative follow-up. This case underscores the necessity of a patient-centered approach to comprehensive breast care for evolving populations and suggests that future gender-affirming needs should be integrated into preoperative breast reconstruction counseling.

Volume

14

Issue

Suppl 4

First Page

15

Last Page

16

Comments

Michigan Academy of Plastic Surgeons 34th Biennial Scientific Meeting, July 12-15, 2026, Mackinac Island, MI

DOI

10.1097/01.GOX.0001276748.09664.18

ISSN

2169-7574

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