Against the backdrop of ongoing therapeutic advances in breast cancer care, post‑mastectomy breast reconstruction has become a key component of a holistic treatment, as it can substantially improve patients’ psychological well‑being and quality of life. Autologous breast reconstruction has established itself as a viable alternative to implant-based reconstruction, utilizing an increasingly wide range of flap options. Since the introduction of the DIEP flap, the field has advanced towards individualized procedures as numerous flap techniques from locations other than the abdomen have been described. To support evidence-based flap selection and a high quality of individualized care, this study focuses on comparing subjective and objective outcomes following breast reconstruction among nine flap types. A special focus was placed on highlighting the differences between abdominal-based and alternative flaps.
The authors analyzed a cohort of 183 patients who underwent autologous breast reconstruction between 2010 and 2022 at the University Hospital Zurich regarding objective surgical outcomes and patient-reported quality of life by using the BREAST-Q. The overall rate of flap-related complications, including partial and complete flap loss, was low and logistic regression analyses showed no significant difference between the abdominal-based and alternative flap groups. However, the authors found a significant difference in donor-site morbidity requiring surgical revision, which was higher in the abdominal group (OR 0.196, 95% CI 0.045-0.857, p = 0.03). Despite this disparity, the BREAST-Q results showed no relevant differences in satisfaction and well-being between the two donor-site groups.
These findings support the importance of individualized patient care and shared decision-making, suggesting that both abdominal-based and alternative free flaps can achieve similarly high levels of patient satisfaction when body habitus, donor-site availability, and patient preference are considered during preoperative planning. While different flap types have distinct anatomical profiles leading to expected trade-offs, the patient’s perceived reconstructive success appears to depend more on successful shared decision-making and personalized choice.
Interview with Lisanne Grünherz, Stella Vocke* and Nicole Lindenblatt
* Abdominal-based vs. (versus) Alternative flaps: surgical outcomes and quality of life following different techniques of autologous breast reconstruction (Master’s thesis, University of Zurich, 2025)
What inspired you to conduct this study?
Several studies have shown that breast reconstruction following mastectomy is associated with improved quality of life and enhanced psychological well-being, thereby highlighting how crucial successful breast reconstruction is for patients. At the same time, surgical practice has evolved to encompass a growing range of alternative flaps beyond the abdominal-based DIEP flap, especially important for women with limited abdominal tissue. Given the continuous evolution of flap reconstruction techniques, ongoing research is essential to refine indications and identify optimal solutions for individual patients. While some techniques have been well studied, comparative data particularly between abdominal-based and alternative flaps remain limited. We therefore aimed to evaluate objective outcomes and quality of life in a cohort undergoing different techniques of autologous breast reconstruction. Additionally, one of the co-first authors completed her master’s thesis based on this research project, which deepened the academic engagement with the topic and offered an extensive literature review.
Were there any unexpected findings?
Interestingly, we did not observe any significant difference in the number of touch-up procedures performed after autologous breast reconstruction using alternative free flaps compared to abdominal-based flaps. This was an unexpected observation given the susceptibility of muscular flaps to undergo denervation-related muscle atrophy after transplantation, leading to volume loss. Such volume deficits are commonly corrected through secondary fat grafting.
What is the direct impact on the surgeon's work?
Our findings support an individualized approach to flap selection. For suitable candidates identified through careful preoperative planning, surgeons can consider alternative donor sites for autologous breast reconstruction. Careful consideration of individual anatomy and patient preferences is essential, and whenever feasible, patients should be actively involved in the planning process within a shared decision-making framework.
What is your learning point from this project?
A key learning point is that there is no single “gold standard” for autologous breast reconstruction; rather, the optimal approach should be individualized to each patient. Although the various flap techniques each present distinct advantages and limitations due to their specific anatomical characteristics, consistently high levels of patient satisfaction can generally be achieved across different flap types when the flap matches the patient’s body habitus and preference.
Are there any subsequent projects planned?
This study has highlighted several areas where further research would be beneficial. As the data reflects short- to medium-term results, evaluating long-term outcomes of alternative free flaps would help to understand of how different flap types behave over time, for example regarding volume stability, long-term donor-site morbidity, and sustained patient satisfaction. Additionally, by comparing the results of this study with those from other institutions, the evidence base could be strengthened for the findings limited by the relatively small size of subgroups per flap type. We believe that there is considerable room for further investigation in this field and hope that the study contributes to a growing body of evidence supporting individualized, patient-centered approaches to autologous breast reconstruction.
