DIEP Flap versus PAP Flap versus LAP Flap: A Propensity-Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction.

Background: As free breast reconstruction options evolve, a patient- and body-centric approach can distinguish refined aesthetic outcomes. Although deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), and lumbar artery perforator (LAP) flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these 3 flaps has not been performed. The authors aim to compare these 3 flaps based on outcomes, BREAST-Q scores, and aesthetic results.

Methods: After institutional review board approval, a retrospective review in a Research Electronic Data Capture database-guided analysis was conducted of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Postoperative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population.

Results: Overall patient postoperative breast satisfaction was insignificantly different across the 3 flap groups ( P > 0.05). Associations were seen with LAP flap donor-site seromas, PAP flap donor-site infections and wounds, and DIEP flap breast wounds and flap necrosis ( P < 0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis ( P < 0.05).

Conclusions: DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. Although DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes.

Clinical Question/level Of Evidence: Therapeutic, III.