Tuesday, November 4, 2008 - 2:30 PM

Patient Satisfaction in DIEP Flap Breast Reconstruction: A Comparative Evaluation with TRAM Flap, Latissimus Flap, and Implant Techniques

Janet H. Yueh, BA, Eran D. Bar-Meir, MD, Adam M. Tobias, MD, Theodore T. Nyame, BA, Bernard T. Lee, MD, Donald J. Morris, MD, and Sumner A. Slavin, MD.

Introduction:  Breast reconstruction is an essential component of the overall treatment plan for patients considering mastectomy.  As perforator flap techniques, such as the deep inferior epigastric perforator (DIEP) flap, continue to gain in popularity there is still no consensus on the optimal method of reconstruction. Over the past decade, patient satisfaction has gained widespread recognition as an important outcome measure for quality of care.  The purpose of this study is to compare patient satisfaction with the DIEP flap to the more commonly practiced techniques in breast reconstruction and identify factors influencing satisfaction.

Methods:   A retrospective chart review was performed on all women who had undergone post mastectomy breast reconstruction at an academic teaching hospital.  A total of 604 patients who had a primary reconstruction with a tissue expander/implant, latissimus dorsi flap, pedicled or free transverse rectus abdominis myocutaneous (TRAM) flap, and deep inferior epigastric artery perforator (DIEP) flap were identified between the years of 1999 and 2006.   Both unilateral and bilateral procedures were included as well as immediate and delayed reconstructions.  A questionnaire was designed to collect the following information from patients after reconstruction: (1) demographic information, (2) types of breast reconstruction options presented, (3) assessment of patient satisfaction with their procedure consisting of the seven general and aesthetic questions developed by the Michigan Breast Reconstruction Outcome Study, and (4) health related quality of life questions provided by the SF-12 Health Survey Questionnaire.  Comparison of dichotomous variables across reconstructive groups was performed using a Fisher's exact test or Chi squared test.  Quality of life rating scales were compared across reconstructive groups using one-way analysis of variance.  Statistical significance was indicated for values of p < 0.05.

Results:  Patient response to the questionnaire was 64.2 percent, with 388 completed questionnaires returned.  This group included 72 tissue expander/implant patients, 94 latissimus dorsi flap patients, 122 TRAM flap patients, and 100 DIEP flap patients.  There were no significant differences in the SF-12 quality of life scores among the four groups.  In comparison to all the other reconstructive procedures, the DIEP flap patients had the highest levels of general and aesthetic satisfaction (p = 0.007 and p = 0.021).  Reconstruction using an abdominal donor site (DIEP, TRAM) had a significantly higher general and aesthetic satisfaction rate than non-abdominal reconstructions (p = 0.009 and p = 0.004, respectively).  When compared directly with the TRAM flap group, the DIEP flap group had a higher general satisfaction rate, however, the aesthetic satisfaction rate was similar.  The timing of breast reconstruction after mastectomy showed a trend towards higher satisfaction rates in immediate over delayed reconstruction.   Patients who underwent unilateral and bilateral breast reconstructions had similar overall satisfaction scores; however, subgroup analysis indicated that the bilateral TRAM cohort had a lower general satisfaction rating (p = 0.041).  Whether patients had mastectomy for treatment of breast cancer or prophylaxis, satisfaction rates were similar.  Finally, as the age of the patient increased at the time of reconstruction, there was a trend towards lower general satisfaction levels (p = 0.086); however aesthetic satisfaction remained relatively constant over different age groups.

Conclusions:  Breast reconstruction with the DIEP flap has the highest patient satisfaction rates among the four types of reconstruction evaluated.  Although reconstruction based on an abdominal donor site revealed higher overall levels of satisfaction, the DIEP flap patients had a higher general satisfaction level when compared to a traditional TRAM flap.  Patient reported aesthetic satisfaction rates were similar among the various autologous techniques and higher than implant-based reconstruction.  Discussing satisfaction outcomes with patients will help in making educated decisions about breast reconstruction.

Table:  Patient satisfaction among the four reconstruction options.


Tissue expander / Implant

Latissimus dorsi +/- Implant

Pedicled & free TRAM



General Satisfaction






Aesthetic Satisfaction