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Comparison of Aesthetic Results and Quality of Life after Breast Reconstruction by DIEP vs. PAP, SGAP, TUG and Latissimus Dorsi

Published Date: September 28, 2017

Comparison of Aesthetic Results and Quality of Life after Breast Reconstruction by DIEP vs. PAP, SGAP, TUG and Latissimus Dorsi

Samah Abedalthaqafi1,2*, Vincent Hunsinger1, Nawaf Aljudaibi2, Kevin Haddad1Julia Salleron3, Mikael Hivelin1, and Laurent Lantieri1

1Department of Plastic Surgery, Européen Georges Pompidou Hospital, Assistance Publique des Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France

2Department of Plastic, Reconstructive and Aesthetic Surgery, King Fahad Hospital (MOH), Jeddah, Saudi Arabia

3Department of Biostatistics, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France

*Corresponding author: Samah Abedalthaqafi, Department of Plastic Surgery, Européen Georges Pompidou Hospital, Assistance Publique des Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France, Tel: +33 1 56 09 58 71; E-mail:

Citation: Abedalthaqafi S, Hunsinger V, Aljudaibi N, Haddad K, Salleron J, et al. (2017) Comparison of Aesthetic Results and Quality of Life after Breast Reconstruction by DIEP vs. PAP, SGAP, TUG and Latissimus Dorsi. Ely J Surg 1(1): 103




Background: The donor site is rarely discussed when planning for breast reconstruction. The aesthetic outcome, and its impact on quality of life, plays an important role in patient satisfaction. We are comparing the SGAP (superior gluteal artery perforator) flap, PAP (profunda femoral artery perforator) flap, TUG (transverse upper gracilis) flap and LD (latissimus dorsi) flap to the DIEP (Deep Inferior Epigastric Artery) flap. The aim of this study is to evaluate patient satisfaction regarding donor site aesthetic results and to help the surgeon and patient make the best decision regarding reconstruction.

Methods: In a retrospective unicentric study, we included 34 patients who underwent bilateral or unilateral breast reconstruction using an autologous free flap. All patients answered two questionnaires: the first was the study design survey and the second was the short form 36 (SF 36) survey. We divided the candidates into two groups – Group A (DIEP) and Group B (other flaps).

Results: We found that 94% of patients in Group B were satisfied about aesthetic results of their breast(s) compared to 82% in Group A. Additionally, 76% of patients in Group A preferred their donor site (abdomen) after the intervention compared to 23% in Group B.

Conclusion: We conclude that a detailed pre-operative consultation regarding the type of flap used and the potential outcome of both the breast and donor site will help the surgeon and patient make the best decision.

Keywords: Breast reconstruction; Free tissue flaps; Quality of life; Microsurgery

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Breast reconstruction following a mastectomy can be of three types; breast reconstruction with implants, reconstruction with a free or pedicled flap, or reconstruction with adipose tissue grafting.

Despite a typically natural satisfactory outcome of the reconstructed breast with surgeries involving flaps, such as in deep inferior epigastric perforator (DIEP) flap surgery, it is important to mention that these techniques can expose the donor site to a number of cosmetic complications, such as a high and visible scar and a widening of the umbilicus [1,2]. DIEP is currently considered the gold standard for autologous breast reconstruction [3]. Other flap techniques based on autologous reconstructions—including profunda artery perforator (PAP) flap [4], superior gluteal artery perforator (SGAP) flap [5], latissimus dorsi (LD) flap, and transverse upper gracilis (TUG) flap—have been widely described in the literature. However, the latter techniques, which have been reserved in our facility for cases lacking abdominal laxity, can result in the formation of “dog ears” (i.e., excess skin at the corners of the incision) or functional restrictions, which can affect the overall satisfaction and quality of life for the patient. The availability of these numerous options allows the surgeon to select the best technique for a given patient, which takes into account the patient’s morphology and her medical history, as well as the impact that the surgery may have on the patient’s social life and physical activities. Within this context, the aim of this study is to compare the abdominal donor site in DIEP to other flap techniques in regard to quality of life and patient satisfaction.

In this study, we evaluated the quality of life and satisfaction in relation to the donor site in patients who had undergone reconstructive surgery using different techniques (DIEP, LD, PAP, TUG, and SGAP), and compared the DIEP group to those who had benefited from the other reconstructive modalities.

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This study was performed as a single-centre retrospective study. Only patients who had undergone breast reconstruction with a flap procedure in our unit, between April 2013 and June 2014, were included (Figure 1). Patients who had undergone breast reconstruction without a flap and, thus, who had no scar on the donor site were excluded. In addition, exclusive lipofilling with or without BRAVA® and breast reconstruction with an implant and no flap were also excluded from the study.

Figure 1: Collected data with p-values.


Patients were divided into two groups – Group A, comprising patients who had undergone reconstruction by DIEP, and Group B, comprising patients who had undergone reconstruction by other flap techniques at the donor site. Socio-demographic and clinical data were extracted from electronic medical files.

After the patients have given their informed consent, they were requested to answer two questionnaires over the phone. Specific epidemiological data considered include the patient’s age, medical history, the date of the first and second surgery, and their waist and hip circumference. Patients were asked to provide answers to nine questions related to their overall level of satisfaction and their ability to resume their usual activities (Table 1).

Table 1: Self-assessment questionnaire.


A four-level Likert scale was used to evaluate two questions out of the nine on the questionnaire, with the options; no, most likely no, yes, most likely yes. The other questions were binary and could be answered by a simple yes or no reply. A short form 36 (SF 36) standard questionnaire, translated into French, that targeted the quality of life, was also conducted.

Data Analysis


All statistical analyses were performed with SAS software version 9.3 (SAS Institute Inc., Cary, NC 27513 USA). Parametric values comprised the median, mean and standard deviation, while the qualitative data were expressed in terms of frequency and percentage. The Shapiro–Wilk test was used to find out if the quantitative data fitted a normal distribution. Parametric values were then compared with the Mann-Whitney test or student t-test when the distribution was considered normal. Qualitative parameters were compared using the chi-squared test or exact Fisher test when the sample size was sufficient. The level of significance was set at 5%.

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The study involved 34 patients whose ages ranged from 35 to 69 years (mean age of 47 years), all of whom had benefited from a bilateral or unilateral breast reconstruction using an autologous flap. A total of 17 DIEP, 3 PAP, 5 SGAP, 2 TUG, and 7 LD surgeries were performed. The mean body mass index (BMI) in Group A was higher than in Group B (26.9 versus 22.8, respectively). The mean follow-up was at 18.6 months. No significant difference was found for the waistline data between the two groups.

Group A donor site complications were postoperative hematoma needed re-operation and drainage at day 1for two patients and one patient presented a hypertrophic scar which required scar physiotherapy. In Group B three patients developed seroma at the donor site (LD flap) treated with multiple punctures and aspirations in the clinic without infection.

Statistical analysis of the specific questionnaire data did not reveal any difference in regard to the overall satisfaction levels between Group B (94.1%) and Group A (82.3%).

The patients from both groups said that they would recommend the same surgical approach to their family members and close friends, and would have chosen the same option if they had to go through the process of reconstruction again. More than 46% of the patients in Group A said that they were self-conscious about the appearance of their abdomen (donor site) before surgery, while only 11% in Group B (other donor sites; back, thigh, hip) expressed the same feeling (p = 0.0239). In Group A, 76.5% of the patients versus 23.5% in Group B (p = 0.002) noticed a definite improvement in the cosmetic appearance after surgery. In Group A, 47% of patients experienced difficulties resuming sports activities, while 17.6% of Group B patients who underwent LD reconstructive procedure were unable to carry heavy loads since the operation (p = 0.0068). Group A patients were more likely to feel comfortable and accept their reconstructed breast than those in Group B (88.4% versus 82.3%, respectively). Moreover, in Group A, 64.7% of the patients were satisfied with their breast cosmetic aspect, in contrast to only 52.9% of Group B patients (Table 2).

Table 2: Outcome of the study questionnaire. (*Nc = Not calculated)


No major difference in the quality of life was noted between the two groups after surgery, except for SPF, a parameter of physical functioning (p = 0.02), which was found to be higher in Group B. The scores obtained during the evaluation of the physical component summary (PCS) as well as from the mental component summary (MCS) were too high and, thus, could not be compared (Table 3).

Table 3: Outcome of the quality of life questionnaire (SF-36).

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The purpose of the present paper is to review our experience in terms of issues with the donor site. Therefore, aspects related to prostheses or adipose tissue grafting is not considered herein.

The DIEP flap technique is currently widely regarded as the gold standard in the field of literature related to breast restorative surgery. DIEP achieves reliable results in 95–99.5% of cases [3,5,6]. The rate of partial necrosis with the DIEP flap procedure is around 2.5% [6], while cytosteatonecrosis has been found to occur in 12.9% of cases. The risk of hernia, which is around 0.7% in unilateral DIEP flap surgery, increases to 2.1% when the procedure is bilateral. Thus, requiring the patient to wear an abdominal compression garment for six weeks post-surgery. A study led by Gil and collaborators [6] over a ten year period, including 758 DIEP cases, revealed a complication rate of 13.6%. These complications were generally related to delayed wound healing at the donor site and abdominal hernia. These complications were observed more in patients who smoke or those who had undergone chemotherapy.

The LD procedure is preferably indicated in patients presenting an important dorsal adiposity. Complications, such as post-operative seromas (which is observed in up to 55% of patients) or delayed wound healing at the donor site (which is observed in 7% of cases [7]), can postpone the patient being able to resume their usual daily activities. According to Lindergens et al. [8], the majority of plastic surgeons are in favor of the DIEP flap technique. However, on the other hand, the majority of patients opt for LD as their preferred breast reconstructive method. The reason for this being the patient’s choice, despite the morbidity risk associated with this type of flap, lies in the fact that the scar at the donor site of the LD flap is more discrete.

The SGAP, PAP, and TUG procedures are appropriate to use in cases where only a small volume is needed to obtain a satisfying breast volume or if there are old scars along the midline, which could decrease the blood supply to the flap and, thus, delay wound healing at the level of the donor site. These flaps are suitable for patients presenting with a gynoid morphology or excessive fat tissue in the lower part of the body: this category of patients does not need a large breast volume and could benefit from a discrete scar (Figures 2A, 2B, 2C). On a technical level, the SGAP and PAP flaps are less currently performed than DIEP, as they require a higher level of surgical dexterity to perform the challenging dissection of the perforators. Also, the resulting scar may be enlarged and sometimes hollow [9]. Furthermore, the scar resulting from the SGAP flap leads to visible asymmetry and prevents the patient from sitting during the immediate post-operative course [10].

Figure 2: Post-operative photos for PAP breast reconstruction. A: Face-on photo of the reconstructed breast; B: Profile photo of the reconstructed breast; C: Aspect of the scar on the donor site (left thigh).


Joyce et al. [11] found that 40% of patients preferred the post-operative cosmetic aspect of the SGAP donor site, while only 16.87% favored the results after the DIEP procedure. These results do not agree with the findings of our study, where 76% of Group A patients mentioned a definite improvement of the donor site: albeit, it is worth mentioning that 47% of these patients were self-conscious about the appearance of their abdomen before the surgery (p = 0.0239).

A retrospective assessment of the abdominal scar after breast reconstruction with the DIEP procedure, conducted by Niddam et al. [2] indicated that 52% of the patients were satisfied and even very satisfied about their belly appearance. Based on this study, patients who complained about their pre-operative BMI, particularly those presenting a more important abdomen pendulum, said that they were satisfied by the post-operative cosmetic results. In our study, the mean BMI of Group A was 26.9 before surgery and 27.5 after surgery: this may be explained by the delayed return to sports activities (Figures 3A, 3B).

Figure 3: Post-operative photos for DIEP breast reconstruction. A: Face-on photo of the breast and donor site; B: Profile photo of the breast and donor site.


Candidates should be warned of potential complications, such as risk of blood transfusion, necrosis, infection, or reopening of the scar [12,13]. Psycho-emotional stress leads in some patients to overestimation of the cosmetic results: unrealistic expectations may result in a sense of regret, perhaps even a rejection of this new breast [14,15].

Numerous studies focusing on the quality of life that used the SF 36 questionnaire have shown that some patients who had undergone the LD procedure complain, in the post-operative course, of intense pain caused by the muscle flap. On the other hand, some patients included in the DIEP group reported severe tiredness after the surgery [7]. Our study revealed that Group A patients did not quickly resume their sports activities, while Group B patients, and particularly those who had benefited from LD, experienced back pain, which prevented them from carrying loads (running errands, baby lifting, weight lifting in the work place, etc.). Our findings are similar to those reported by other studies in DIEP technique: the patients were able to resume work but they faced difficulties in carrying out household chores and their sport activities remained very limited [16].

It is mandatory to openly inform patients about all the risks and potential consequences arising from surgery. The type of flap has not been shown to affect quality of life.



We are immensely grateful to Ms. Christine Degland, from the Association of Breast Reconstruction by D.I.E.P. (, for her help in conducting this study.

Conflict of Interest


Authors declared no conflict of interest.

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Copyright: © 2017 Abedalthaqafi S, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.