Comparative outcomes of DIEP flap and breast implants in breast reconstruction post mastectomy: A systematic review and meta analysis

Background: Breast reconstruction following mastectomy plays a key role in restoring body image and improving quality of life in breast cancer survivors. Implant-based reconstruction (IBR) is widely used due to shorter operative times and the absence of donor-site morbidity, whereas autologous reconstruction using deep inferior epigastric perforator (DIEP) flaps may provide more natural aesthetic outcomes and greater long-term stability. This systematic review and meta-analysis aimed to compare patient-reported outcomes and adverse events between DIEP flap reconstruction and IBR following mastectomy.

Methods: A systematic search of MEDLINE, CENTRAL, and Google Scholar was conducted in June 2025 (PROSPERO registration: CRD420251081966). Studies directly comparing DIEP flap reconstruction with IBR in post-mastectomy patients were included. Eligible studies reported BREAST-Q outcomes and/or surgical complications, reconstruction failure, and revision surgery rates. Two reviewers independently screened studies and extracted data. Risk of bias was assessed using Cochrane RoB 2.0 for randomized controlled trials and ROBINS-I for non-randomized studies. Certainty of evidence was evaluated using the GRADE approach. Pooled mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated using appropriate meta-analytic models.

Results: Twenty studies comprising 3,106 patients were included, of whom 1,068 underwent DIEP flap reconstruction and 2,038 received IBR. DIEP flap reconstruction was associated with significantly higher overall BREAST-Q scores compared with IBR (MD +9.28; p = 0.008), reflecting improved breast satisfaction, psychosocial well-being, and sexual well- being. No significant differences were observed in nipple satisfaction or chest physical well- being. Rates of postoperative infection, hematoma, and seroma were comparable between groups. DIEP flap reconstruction demonstrated a significantly lower risk of reconstruction failure (OR 0.15; p = 0.019). However, donor-site morbidity and revision surgery rates tended to be higher in the DIEP flap group. No significant differences were identified in anxiety or depression outcomes.

Conclusions: DIEP flap reconstruction following mastectomy may provide superior patient- reported satisfaction and lower reconstruction failure rates compared with implant-based reconstruction, without increasing overall complication rates. These potential benefits must be balanced against greater operative complexity, donor-site morbidity, and increased resource requirements. Given the generally low certainty of the available evidence, further high-quality, multicenter studies with standardized outcome reporting are needed to support informed, patient-centered decision-making in breast reconstruction.