DIEP versus SIEA flap in autologous breast reconstruction: a systematic review and meta-analysis

Introduction While 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 remains heterogeneous and controversial. Methods A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420251149245). PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library were searched from inception to September 16, 2025. Comparative studies evaluating SIEA and DIEP flaps in ABR were included. Primary outcomes were 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), driven primarily by increased arterial insufficiency. Venous congestion did not differ significantly between 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 were significantly less frequent in the SIEA group (OR 0.26, 95% CI 0.08–0.84; p=0.04). PROMs showed no sustained advantage of SIEA flaps. Conclusions Across the literature, the DIEP flap demonstrated superior vascular reliability, compared with the SIEA flap. The SIEA flap should be reserved for carefully selected patients with favourable anatomy and adequate vessel calibre. Further prospective studies using standardized outcomes and validated PROMs are warranted. Level of Evidence Level III