Perforator Characteristics and Impact on Postoperative Outcomes in DIEP Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

Background High-quality evidence on perforator selection in deep inferior epigastric perforator (DIEP) flap harvesting is lacking, making preoperative planning and choice of perforators surgeon-specific. This lack of consensus is a subject of continuous debate among microsurgeons. We aimed to systematically review perforator characteristics and their impact on DIEP flap breast reconstruction outcomes. Methods We conducted a systematic review and meta-analysis across six databases: ClinicalTrials.gov, Cochrane Library, Medline, Ovid Embase, PubMed, and Web of Science for all studies on DIEP flap breast reconstruction focused on perforator characteristics-caliber, number, and location. The primary goal was to analyze the impact of perforator characteristics on partial and/or total flap failure and fat necrosis. Data was analyzed using RevMan V5.3. Results Initial search gave us 2,768 articles of which 17 were included in our review. Pooled analysis did not show any statistically significant correlations between partial and/or total flap failure and perforator number, or perforator location. Sensitivity analysis accounting for heterogeneity across studies showed that, the risk for fat necrosis was significantly higher if single perforators (relative risk [RR] = 2.0, 95% confidence interval [CI] = 1.5-2.6, I ²= 39%) and medial row perforators (RR = 2.7, 95% CI = 1.8-3.9, I ²= 0%) were used. Conclusion Our findings suggest that a single dominant perforator and medial row perforators may be associated with higher risk of fat necrosis after DIEP flap breast reconstruction. Adopting a standardized perforator selection algorithm may facilitate operative decision making, shorten the learning curve for novice surgeons, and optimize postoperative outcomes by minimizing the burden of major complications. This in turn would help improve patient satisfaction and quality of life.