DIEP vs. PAP vs. LAP: A propensity matched analysis

Plastic and Reconstructive Surgery, October 2024

Key Takeaways

• All three flap types (DIEP, PAP, LAP) yield similar patient satisfaction scores and complication profiles.

• DIEP flaps had higher breast wound and necrosis rates.

• PAP flaps showed higher donor-site infections and wounds.

• LAP flaps were most often rated superior in matched aesthetic head-to-head comparisons.

Background

Autologous breast reconstruction offers higher satisfaction than implants. While DIEP flaps are the standard, PAP and LAP flaps provide viable alternatives for patients with abdominal contraindications.

Objective

To compare DIEP, PAP, and LAP flaps in terms of postoperative complications, patient-reported satisfaction (BREAST-Q), and aesthetic outcomes using crowdsourced ratings.

Methods

• Retrospective review of 150 patients (50 per flap type) who underwent bilateral reconstruction.

• Propensity matching based on age, BMI, comorbidities, and treatment exposure.

• Assessed postoperative complications, BREAST-Q scores, and crowdsourced aesthetic ratings of matched postoperative images.

Results

• Demographics: No significant differences in age, BMI, race, or comorbidities.

• Complications:

  • DIEP: Higher breast wound (22%) and necrosis (14%) rates.

  • PAP: Higher donor-site wounds (32%) and infections (14%).

  • LAP: Higher donor-site seromas (20%).

• BREAST-Q Scores: No statistically significant differences. LAP had higher satisfaction in breast and psychosocial domains; PAP scored higher in sexual well-being.

• Aesthetics: DIEP flaps had highest average global rating. However, LAP flaps were most frequently preferred in matched pair image comparisons (P < 0.05).

Complication / Outcome	DIEP (%)	PAP (%)	LAP (%)
Breast Wound	22%	4%	6%
Flap Necrosis	14%	0%	2%
Donor-Site Infection/Wound	4%	32%	14%
Aesthetic Preference	33%	18%	49%

Conclusion

All three flaps are safe and yield high satisfaction. LAP flaps may provide superior aesthetic results when matched for patient morphology. Flap choice should be tailored to patient anatomy, goals, and surgeon experience.

Strengths and Limitations

• Strengths: Propensity matching, multi-dimensional outcome assessment, inclusion of patient-reported and aesthetic outcomes.

• Limitations: Single-center design, potential bias from surgeon experience, unequal BREAST-Q response numbers.

Future Directions

• Evaluate progressive tension sutures for LAP donor sites.

• Explore impact of surgical experience and technique evolution over time.

• Long-term studies assessing aesthetics and function across broader populations.

Clinical Relevance

This study supports a tailored approach in flap selection. Surgeons should consider donor-site characteristics and aesthetic potential in line with patient-specific goals and body morphology.