PAP Versus DIEP Flap Breast Reconstruction: Current Evidence and the Unresolved Question of Timing and Oncologic Safety – A Narrative Review

Background/Objectives: Deep inferior epigastric perforator (DIEP) flap reconstruction represents the gold standard for autologous breast reconstruction, while profunda artery perforator (PAP) flap reconstruction has developed as a reliable alternative, particularly in patients with low body mass index or inadequate abdominal tissue. Even though several comparative studies have evaluated surgical and patient-reported outcomes between PAP and DIEP flaps, evidence regarding reconstructive timing, oncologic safety, and interactions with adjuvant therapies remains scarce, especially for PAP reconstruction. Methods: A narrative review of the literature was conducted using PubMed. Studies assessing PAP and DIEP flap breast reconstruction were included, with particular focus on surgical outcomes, patient-reported outcomes, reconstructive timing (immediate or delayed reconstruction), oncologic safety, recurrence, and the effects of radiotherapy and chemotherapy. Comparative studies, cohort studies, systematic reviews, and meta-analyses were synthesized through a narrative review. Results: Twenty studies were included. Comparative evidence showed similar flap survival rates and overall patient satisfaction between the two methods, with flap success rates approaching 98–100%. PAP reconstruction was associated with increased donor-site wound complications and, in some studies, increased fat necrosis rates, while long-term patient-reported and aesthetic outcomes remained equivalent between techniques. In contrast to the relatively limited PAP literature, DIEP reconstruction has been widely studied in terms of reconstructive timing and oncologic safety. Current evidence indicates that immediate DIEP reconstruction does not increase the risk of flap loss, major complications, or recurrence in comparison with delayed reconstruction and might optimize early postoperative recovery and patient-reported outcomes. Nevertheless, none of the identified studies directly compared PAP and DIEP reconstruction with respect to immediate versus delayed timing, exposure to radiotherapy or chemotherapy, or long-term oncologic outcomes. Conclusions: PAP flap appears to represent a reliable alternative to DIEP flap reconstruction. However, major gaps in the literature persist involving PAP reconstruction in oncologic and timing-related settings. Future prospective multicenter studies that directly compare PAP and DIEP flaps according to reconstructive timing, exposure to adjuvant therapy, recurrence, and patient-reported outcomes are warranted to establish evidence-based reconstructive strategies for oncologic breast reconstruction.