DIEP Flap vs PAP Flap Breast Reconstruction: Understanding the Difference

For women considering natural tissue breast reconstruction after mastectomy, two advanced options available today are the DIEP flap and the PAP flap. Both procedures rebuild the breast using a patient’s own tissue rather than implants, creating a natural look and feel.

At The Center for Breast Reconstruction, Dr. Joshua L. Levine performs these highly specialized microsurgical procedures.

In this article we provide detailed medical illustrations to help you understand how each technique works.

While both procedures share the same microsurgical principles, they differ primarily in where the tissue is taken from and which patients they are best suited for.

Both the DIEP flap and PAP flap are known as perforator flap procedures, meaning the surgeon carefully removes skin and fat along with the small blood vessels that supply the tissue, while preserving the surrounding muscle.

The tissue is then transplanted to the chest where it is shaped to form a new breast. Using microsurgery, the surgeon reconnects the tiny blood vessels from the transferred tissue to blood vessels in the chest so that the tissue can establish circulation in its new location.

The primary difference between the two procedures is the donor site, or where the tissue comes from.

The DIEP flap (Deep Inferior Epigastric Perforator flap) uses skin and fat from the lower abdomen to reconstruct the breast.

As shown in the DIEP flap medical illustration, the surgeon carefully identifies the perforating blood vessels that travel through the abdominal tissue. The surrounding abdominal muscles are preserved, which helps maintain core strength.

During surgery:

• Skin and fat from the lower abdomen are removed along with the perforator blood vessels
• The abdominal muscles are left intact
• The tissue is transplanted to the chest
• Microsurgery is used to reconnect the blood vessels to vessels in the chest

Because the tissue comes from the lower abdomen, many patients notice a result similar to a tummy tuck effect at the donor site.

The abdomen often provides enough tissue for moderate to larger breast reconstruction, which is why the DIEP flap is commonly the first option considered when patients are candidates.

The PAP flap (Profunda Artery Perforator flap) uses skin and fat from the upper inner thigh instead of the abdomen.

The PAP flap medical illustration demonstrates how tissue is taken from the area just beneath the buttock crease along the inner thigh. This allows the scar to sit within the natural fold of the body.

During the PAP flap procedure:

• Skin and fat from the upper inner thigh are removed with their blood vessels
• The thigh muscles are preserved
• The tissue is transferred to the chest
• Microsurgery reconnects the blood vessels to restore circulation

The PAP flap is especially helpful for patients who:

• Do not have enough abdominal tissue for a DIEP flap
• Have had previous abdominal surgery
• Prefer reconstruction that uses tissue from the thigh

Although the amount of tissue available from the thigh is typically smaller than the abdomen, PAP flaps can still create very natural reconstruction results.

The best procedure depends on a number of factors, including:

• Your body shape and available donor tissue
• Previous surgeries
• Desired breast size
• Overall health and surgical history

Many women are ideal candidates for DIEP flap reconstruction, but the PAP flap provides an excellent alternative when abdominal tissue is not available.

A consultation with an experienced microsurgical breast reconstruction specialist allows for a detailed evaluation of potential donor sites and reconstruction goals.

Both DIEP and PAP flap procedures offer important advantages compared with implant-based reconstruction.

These include:

• Reconstruction using your own living tissue
• A breast that looks and feels natural
• No implants to maintain or replace
• Long-term durability

Preservation of important muscles at the donor site

Because the reconstructed breast is made from your own tissue, it can respond more naturally to changes in weight and aging over time.

Choosing the right reconstruction technique requires careful planning and surgical expertise. At The Center for Breast Reconstruction, Dr. Levine works closely with each patient to determine the most appropriate approach based on their anatomy and goals.

Detailed medical illustrations of the DIEP flap and PAP flap procedures are also used during consultations to help patients visualize how the reconstruction is performed and where the donor tissue will come from.

For many women, advances in microsurgical reconstruction mean there are now multiple natural tissue options available, even when abdominal tissue is not suitable.

What is the difference between a DIEP flap and a PAP flap?

The main difference between a DIEP flap and a PAP flap is the donor site used for the reconstruction. The DIEP flap uses skin and fat from the lower abdomen, while the PAP flap uses tissue from the upper inner thigh. Both procedures preserve muscle and use microsurgery to reconnect blood vessels.

Who is a candidate for PAP flap breast reconstruction?

The PAP flap is often recommended for patients who do not have enough abdominal tissue for a DIEP flap or who have had previous abdominal surgery. It provides a natural tissue reconstruction option using tissue from the upper inner thigh.

Is DIEP flap better than PAP flap?

Neither procedure is universally better. The best option depends on a patient’s anatomy, available donor tissue, and surgical history. During consultation, a microsurgical breast reconstruction specialist evaluates which procedure may provide the best outcome.

Can PAP flap and DIEP flap reconstruction look natural?

Yes. Both DIEP and PAP flap procedures use the patient’s own living tissue, which can create a breast reconstruction that looks and feels natural.