DIEP Flap Surgery Best for Natural Breast Reconstruction Results?

In my San Francisco area practice I have been able to offer my patients a wide range of reconstructive options. I've had the opportunity to co-found a breast reconstruction program and found two microsurgical programs which primarily have focused on breast reconstruction.
The two basic categories of breast reconstruction include implant reconstruction (typically tissue expander followed by a permanent implant) and autologous tissue (using your own body's tissue to reconstruct your breast).
I believe that if you are going to use autologous tissue a DIEP flap (or a muscle sparing free TRAM where some of the rectus muscle is taken) gives superior results to a tradition TRAM (where the abdominal tissue is based on the rectus muscle and remains attached).
Specific benefts of a free TRAM or DIEP operation vs. a pedicled TRAM include:

Typically able to use more of the abdominal tissue to reconstruct the breast because the microsurgical options typically provide a better blood supply.
Eliminates the abdominal bulge sometimes present when you turn the TRAM flap (the bulge is created by the attached rectus muscle).
Better abdominal wall strength with decreased risk of hernia (this is because the TRAM flap sacrifices the entire rectus muscle whereas the DIEP and muscle sparing free TRAM leave the bulk of that muscle intact and functional.

With regard to cost - microsurgical breast reconstruction is a much larger operation. It typically takes me 2-3 hours to perform a pedicled TRAM breast reconstruction. A microsurgical breast reconstruction (DIEP, SIEA, free TRAM, SGAP) typically takes 5-6 hours.
In addition - patient's need a significantly longer recovery time from a microsurgical breast reconstruction and my patient's (and this is typical) stay in the intensive care unit for several days for close monitoring of the microsurgical areterial and venous connections.
While autologous tissue breast reconstructions are significantly more laborious and require greater time to recovery (microsurgical or not), most experts agree that an implant breast reconstruction looks best at about 6 - 24 months after surgery and begins to look worse overtime whereas autologous tissue reconstructions look reasonable about 6 months post-op and improve over the next year and are incredibly lasting in terms of natural appearance.
In addition, using your own tissue has the benefit of being resistant to infection, capsular contracture, implant rupture, etc.
The bottom line is you need individualized review of your options and it should come from a board certified plastic surgeon who performs ALL types of reconstruction - so you get a non-biased answer.
Interestingly, in terms of numbers, if you look at all comers most people get breast implant reconstructions likely because many surgeons don't perform microsurgical breast reconstruction and because insurance compensation is better for implant reconstruction (in terms of compensation vs. amount of work - no one would argue that implant reconstruction is more laborious than microsurgical breast reconstruction). If you isolate cost as a factor (ie look at university programs or centers of excellence where insurance compensation may not be as large a factor) many more people get autologous breast reconstruction, likely because of the superior results.
Please do not hesitate to contact my office if you have additional questions regarding breast reconstruction.

DIEP surgery uses excess lower abdominal skin and fat to replace a breast removed through mastectomy with soft, warm tissue from your own body.  This surgery is very complicated and requires a skilled and experienced surgeon at a center that also performs these surgeries frequently.  Despite the complexity of the procedure, the vast majority of the time it is successful and results in a breast that feels and looks very natural.  After reconstruction is complete, your breast will continue to change with you over time, mimicing the changes of a natural breast with changes in weight and with time.

I work in Oakville, Canada.  Everything related to breast cancer reconstruction is covered by OHIP.  I have a strong bias towards DIEP flaps.  No doubt it is a longer surgery and has potential complications.  But most of the time it works out really well.  You can get excellent results with implants and autologous tissue (using your own body).  However, more times than not the result is more natural using your own body.  Talk to your surgeon to see if you are a candidate.