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DIEP versus SIEA flap in autologous breast reconstruction: A systematic review and meta-analysis
Marco Morelli Coppola1, Beniamino Brunetti2, Carolina P Mureddu2
1Department of Plastic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Research Unit of Plastic, Reconstructive and Aesthetic Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Division of Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Introduction:
Although the deep inferior epigastric artery perforator (DIEP) flap is regarded as the gold standard in autologous breast reconstruction (ABR), the superficial inferior epigastric artery (SIEA) flap has been proposed as a muscle- and fascia-sparing alternative. However, evidence comparing outcomes between these techniques continues to be heterogeneous and controversial.
Methods:
A systematic review and meta-analysis were conducted according to the PRISMA 2020 guidelines and was prospectively registered in PROSPERO (CRD420251149245). The PubMed/MEDLINE, Embase, Scopus and the Cochrane Library databases were searched from inception to September 16, 2025. Comparative studies that evaluated SIEA and DIEP flaps in ABR were included. Primary outcomes included total flap loss, partial flap loss and take-back for vascular compromise. Secondary outcomes included abdominal bulge/hernia, seroma, liponecrosis and patient-reported outcome measures (PROMs). Random-effects meta-analyses were performed.
Results:
Nineteen studies were included. SIEA flaps were associated with significantly higher odds of total flap loss (OR 5.42, 95% CI 2.76-10.63; p = 0.0009) and take-back for vascular compromise (OR 3.80, 95% CI 2.50-5.76; p = 0.002), which was driven primarily by increased arterial insufficiency. Venous congestion did not differ significantly between the techniques. Donor-site seroma occurred more frequently after SIEA harvest (OR 5.31, 95% CI 2.94-9.61; p = 0.003), whereas abdominal bulge and hernia occurred less frequently in the SIEA group (OR 0.26, 95% CI 0.08-0.84; p = 0.04). PROMs showed no sustained advantage in using SIEA flaps.
Conclusions:
Across the literature, the DIEP flap demonstrated superior vascular reliability, compared with the SIEA flap. Therefore, the SIEA flap should be reserved for carefully selected patients with favourable anatomy and adequate vessel calibre. Further prospective studies using standardised outcomes and validated PROMs are warranted.
Level Of Evidence:
Level III.
