Comparative Outcomes Of Diep Versus Tram Flaps In Autologous Breast Reconstruction: A Systematic Review

Background: The deep inferior epigastric perforator (DIEP) flap was developed to reduce the abdominal wall morbidity associated with the transverse rectus abdominis myocutaneous (TRAM) flap in autologous breast reconstruction. However, the comparative safety and outcomes of these techniques remain a subject of debate. Objective: This systematic review aims to qualitatively synthesize and compare the evidence on donor-site morbidity and flap-related complications between DIEP and TRAM flap breast reconstruction. Methods: Following PRISMA 2020 guidelines, a systematic search was conducted in the PubMed, Embase, Scopus, Web of Science, and Cochrane Library databases through October 2025. Comparative human studies evaluating clinical outcomes were included. Data from the final included studies were extracted and synthesized narratively. The risk of bias was assessed using the ROBINS-I tool for non-randomized studies. Results: Six comparative studies were included in the qualitative synthesis. A consistent pattern emerged across studies reporting on abdominal wall morbidity, indicating that the DIEP flap is associated with a substantially lower incidence of hernia and/or abdominal bulge compared to TRAM flaps, particularly the pedicled variant. In contrast, the evidence regarding fat necrosis was inconsistent, with some studies favoring DIEP, others favoring TRAM, and some showing no difference, highlighting significant heterogeneity for this outcome. Rates of total flap loss were low and comparable between techniques. Conclusions: The available evidence consistently supports the use of the DIEP flap over the TRAM flap for reducing donor-site abdominal wall morbidity. The comparative risk of fat necrosis remains uncertain due to conflicting results across studies.