Introduction: The deep inferior epigastric perforator (DIEP) flap was developed in an attempt to decrease abdominal morbidity after breast reconstruction when compared with the conventional free transverse rectus abdominis musculocutaneous (TRAM) flap. However, the advantages of using the DIEP flap over the muscle-sparing free TRAM flap (MS-2) are not well established. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. Ultrasonographic studies demonstrate a significant degree of muscular atrophy after a DIEP flap dissection, and recent works have showed similar donor-site morbidity and functional outcomes, while the DIEP flap is more prone to venous congestion and flap-related complications and may require longer operative times, especially when anatomy is unfavorable.
Methods: The aim of this study was to compare donor-site morbidity and flap-related complications after unilateral breast reconstruction with the MS-2 flap and published data of women reconstructed with unilateral DIEP flaps. The study included 123 women who have had breast reconstruction using the MS-2 flap over a 4-year period. Fifty-seven percent were performed immediately and 43 percent were delayed.
Results: Mean follow-up was 22 months. Outcome included fat necrosis in 18 patients (14.6%), venous congestion in 1 (0.8%), partial necrosis of the flap in 1 (0.8%), and total necrosis in 3 (2.4%). An abdominal bulge occurred in 5 women (4%). Mean operative time was 6.5 hours for immediate reconstruction and 5.8 hours for delayed reconstruction. Comparative results are shown in Table 1.
Conclusion: Our results are similar to those published by other authors using the MS-2 and DIEP flaps. There is no difference in flap-related complications and donor-site morbidity between using the MS-2 flap and the free DIEP flap. However, comparison between data in different series must be interpreted cautiously. Some authors only report complications requiring surgical revision while others not. Fat necrosis is difficult to measure, especially after skin- sparing mastectomy, and some abdominal bulges may be minor and not require reparation. Total necrosis may be attributed to technical problems during vascular anastomosis and not be related to flap dissection. Operative time is not reported in most of the series and may not be compared; however, in our practice dissection of an MS-2 flap takes less time than a DIEP flap.
Most of the authors recommend using the most expeditious and reliable flap based on the vascular anatomy. Thus, on patients whose anatomy reveals perforators of adequate size, the DIEP flap is selected. However, we prefer to perform MS-2 flaps in all the patients, even if their anatomy is favorable for a DIEP flap, obtaining predictable results in less operative time.
Table 1. Comparative results between published data and this study (% of patients with a given complication).

	DIEP (literature data)	MS-2 (literature data)	MS-2 (this study)
Fat necrosis	6-17	5.8-14	14.6
Venous congestion	2-15	3	0.8
Abdominal bulge	1-10.4	2-6.5	4
Partial necrosis	1-7	0.1-1	0.8
Total necrosis	0.5-4.5	0-3	2.4
Operative time (hours)	4.5-7.5	-	5.8-6.5