Clinical and donor-site outcomes of DIEP versus TRAM flaps in post-mastectomy breast reconstruction: a systematic review and meta-analysis

Abstract

Background: Autologous breast reconstruction continues to be a cornerstone of post-mastectomy reconstruction, with abdominally based flaps providing reliable aesthetic and functional outcomes. Of these approaches, the deep inferior epigastric perforator (DIEP) flap and the transverse rectus abdominis myocutaneous (TRAM) flap are the most commonly used. However, controversy exists surrounding their relative effectiveness, complication profile, donor-site morbidity, and reported outcomes.

Methods: A systematic review and meta-analysis were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A search was conducted across PubMed, Scopus, Embase, and Web of Science for comparative studies published between January 2000 and December 2025 that assessed DIEP and TRAM flap breast reconstruction. Outcomes included total flap loss, fat necrosis, donor-site morbidity, abdominal wall complications, and patient-reported outcomes. Random-effects meta-analyses were performed employing pooled odds ratios (ORs) and 95% confidence intervals (CIs). Heterogeneity was evaluated by Cochran’s Q and Higgins’ I² statistics. An exploratory network meta-analysis was also performed to compare DIEP with other autologous reconstructive techniques, such as transverse upper gracilis (TUG), transverse myocutaneous gracilis (TMG), profunda artery perforator (PAP), and inferior gluteal artery perforator (IGAP) flaps.

Results: Ten studies met the inclusion criteria for the qualitative synthesis, yet five also provided quantitative data that were included in the meta-analysis. Pooled analysis showed no significant difference in fat necrosis between reconstructive techniques (OR: 0.86; 95% CI: 0.54–1.36; I² = 34.6%). Likewise, the total flap loss rates were similar between DIEP and TRAM flaps (OR: 0.79; 95% CI: 0.39–1.61; I² = 7.2%). DIEP reconstruction was consistently associated with fewer donor-site morbidities and significantly better maintenance of abdominal wall health than the TRAM flap. Among exploratory network meta-analysis studies, the TUG flap showed clear superiority in reduced total flap loss, while DIEP flaps ranked favorably in donor-site outcomes and patient satisfaction.

Conclusions: DIEP and TRAM flaps have comparable flap survival and overall reconstructive efficacy in post-mastectomy breast reconstruction. DIEP reconstruction appears to offer the best performance in reducing donor-site morbidity while preserving abdominal wall integrity. There was no single reconstruction technique that consistently outperformed all other reconstructive approaches across all outcomes, reinforcing an individualized surgical approach based on patient anatomy, comorbidities, reconstruction goals, and surgeon expertise.