Efficacy and safety of breast reconstruction with free DIEP/TRAM flaps compared to implants and tissue expanders: A Systematic Review

Abstract

Background: Breast reconstruction after mastectomy significantly impacts patient quality of life. While prosthetic techniques are widely accessible, autologous microsurgical options offer a natural alternative. This systematic review aims to compare the clinical efficacy, patient-reported satisfaction, and complication rates between free deep inferior epigastric perforator (DIEP) / transverse rectus abdominis myocutaneous (TRAM) flaps and implant-based reconstruction. Methods: A systematic review was conducted following the PRISMA guidelines. Electronic databases (including PubMed/MEDLINE and the Cochrane Library) were evaluated to identify clinical trials, prospective, and retrospective cohort studies published up to 2026 comparing free abdominal flaps versus prosthetic breast reconstruction. Results: Six high-impact studies met the inclusion criteria, encompassing a diverse cohort of patients. Patient-reported satisfaction (evaluated primarily via the BREAST-Q questionnaire) was significantly higher in the autologous group (DIEP/TRAM) regarding breast appearance, psychosocial well-being, and long-term aesthetic outcomes. Regarding safety, a distinct temporal paradox was identified: prosthetic reconstruction demonstrated lower initial surgical morbidity but higher long-term complication rates (capsular contracture, implant failure, and asymmetry), particularly in patients undergoing post-mastectomy radiotherapy. Conversely, free abdominal flaps exhibited higher early surgical morbidity and donor-site complications, but superior long-term tissue stability and sustained patient satisfaction over multi-year follow-ups. Conclusions: Free DIEP/TRAM flaps provide superior long-term aesthetic satisfaction and quality of life compared to prosthetic breast reconstruction. Although autologous microsurgeries involve greater initial surgical complexity and early morbidity, they demonstrate lower late complication rates, establishing them as a highly reliable and definitive option for appropriate candidates.

Keywords: Breast Reconstruction; DIEP Flap; Breast Implants; Patient Satisfaction; Systematic Review.