Deciding between Implant and Flap Surgery

By Mona Iskander,

Tuesday, May 5, 2015

Plastic surgeon Peter Cordeiro specializes in implants and flap surgery for women with breast cancer

Women undergoing mastectomy as part of treatment for breast cancer not only have to cope with a cancer diagnosis and treatment but the decision of whether to have breast reconstructive surgery. Both options — implant surgery and flap surgery (in which the surgeon uses the patient’s own tissue to reconstruct the breast) — can provide excellent cosmetic results, but it’s important to make the decision in close collaboration with your surgeon.

  • The goal of reconstruction is to restore the breast mound and achieve symmetry.
  • Implant and flap surgery are the two major types of breast reconstruction.
  • Flaps make use of a woman’s own tissue to reconstruct the breast.
  • Flaps offer a larger, softer breast.
  • The best candidates for implants tend to be smaller, thinner women.

A diagnosis of breast cancer can be terrifying enough. Finding out that mastectomy (surgery to remove one or both breasts) is required to treat the cancer can compound the devastation. For some women, the feelings surrounding the loss of one or both breasts can be nearly as overwhelming as the cancer diagnosis itself.

While there’s no procedure that can restore feeling in the breast region after a mastectomy, recent advances have expanded the range of reconstruction options available to women today. Patients can get excellent cosmetic results whether they choose to have the procedure done with implants or using their own tissue, generally known as flap surgery.

At Memorial Sloan Kettering, our plastic surgeons are working tirelessly to refine reconstruction options, and many of them are innovators in the field. Establishing good communication with patients is key to their success. To help you better understand your options, we spoke with Peter Cordeiro, Chief of the Plastic and Reconstructive Surgical Service, whose work has contributed to a number of improvements in breast reconstruction and microsurgery.  

What is the goal of breast reconstruction, and what factors do you take into consideration when making a recommendation?

The goal of breast reconstruction after mastectomy [the removal of a breast] is to restore the breast mound, or mounds, and achieve symmetry. At MSK, breast surgeons [who perform mastectomies] and plastic surgeons [who reconstruct breasts] work closely with medical oncologists, radiation oncologists, and with the patients themselves to develop the optimal surgical treatment and a reconstruction strategy.

The type of breast cancer a patient has — including its location within the breast and the stage of the cancer — her body type, general health status, what additional therapy she may need either before or after surgery, as well as her own wishes regarding the type of surgery she may want are all factors in the recommendations I make to my patients.

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Tell us about implants, since that’s the type of breast reconstruction most of us are familiar with. What does that procedure entail?

The implant is the most common form of breast reconstruction, and it involves the use of either a silicone or a saline implant to rebuild the breast. At MSK, we most commonly use silicone because it’s softer and feels more like a natural breast.

For the vast majority of our patients, implant surgery involves two steps. First, at the time of mastectomy, we place a tissue expander underneath the pectoralis muscle in the chest. After a couple of weeks — once things start to heal — we slowly fill the expander with saline so that the muscle and skin gradually stretch out. On average, the expansion process takes around six to eight weeks. Then, after another six to eight weeks, we remove the expander and put the final implant in its place.

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Is there an ideal candidate for implants?

The best candidates for implants tend to be smaller, thinner women with a B cup breast. Fuller-breasted women can have implant reconstruction, but if they received a unilateral mastectomy [when one breast is removed], we would need to do a reduction on the natural breast in order to achieve symmetry with the implant. Similarly, for women with an A cup breast size, we may need to do a breast augmentation of the natural breast to achieve symmetry.

Implants can occasionally leak or get infected, which may require another procedure down the line. However, implants do provide very good results and are a great option for many women.

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And what about the second option, flap reconstruction? What does that involve?

Flap reconstruction makes use of a woman’s own tissue — including skin, fat, and occasionally muscle — to reconstruct the breast. That tissue and skin can be obtained from a variety of places, and the area and method we choose will depend on factors such as the amount and quality of tissue available as well as the patient’s preference.

TRAM flap reconstruction, the most common of these methods, involves using tissue from the area below the belly button. The skin, fat, and at least one abdominal muscle are tunneled underneath the skin upward into the breast area but remain attached to their blood vessels in the abdomen. This allows the transferred tissue to continue to get its blood supply from where it originated, making it the simplest of the flap procedures. The downside is that it requires sacrificing muscle, which potentially can affect function in the abdominal region.  

At MSK, our overall approach is to sacrifice the least amount of abdominal muscle possible, or in some cases no muscle at all, and we can do that using two newer reconstructive techniques — the free TRAM flap and DIEP flap. These procedures involve the relocation not only of tissue but also of the tissue’s blood supply, which means that microvascular surgery techniques are required to complete them. [Microvascular surgery refers to surgery that’s performed on very small blood vessels using an operating-room microscope and a variety of tiny, special instruments.] In a free TRAM flap, very little muscle is removed, and in DIEP flap the entire abdominal muscle can be spared.

Aside from the abdomen, other areas that often have a lot of tissue are the thighs and the buttocks. The TUG and DUG flaps utilize skin, fat, and a small piece of muscle from the thigh to reconstruct the breast. The gluteus flap utilizes the buttock as a source of skin and fat for breast reconstruction.

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What are the benefits of using your own tissue?

Using your own tissue makes for the most natural-feeling breast. So if you want a larger, softer breast, a flap is a very good choice. That’s the main benefit. With flaps, the newly reconstructed breasts tend to age the same way as a natural breast. You obviously have to have enough tissue available to donate, whether it’s from your abdomen, thigh, or buttock. For women who are too thin, implants are a great alternative.

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What are the risks or downsides to flap surgery?

It takes longer — doing a flap will often add three to eight hours to a mastectomy, whereas an implant usually adds only about 45 minutes. The main downside of doing a flap is the potential impact it has on the area you’re taking the tissue from. If muscle is removed, you risk compromising the affected area.

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What factors might prohibit reconstructive breast surgery?

As a general rule, we at MSK like to consider all patients as potential candidates for breast reconstruction surgery. The ones who aren’t candidates tend to be patients with very advanced disease or those who are very elderly.

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One last question: When is the best time for breast reconstruction — at the time of a mastectomy or afterwards?

We generally recommend reconstruction at the time of mastectomy, unless there are some special circumstances. This allows women to get back to their normal life as quickly as possible. It also spares them from having to undergo a second operation. That said, we see patients at all stages, including women having prophylactic mastectomies or who underwent mastectomy at other hospitals and are now reconsidering their original decision not to have reconstruction.

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What mode of surveillance is necessary post flap
Reconstruction eg mammography etc
Thank you

Thank you for your question. We reached out to Dr. Cordeiro who says that mammography is not necessary for breasts that have been reconstructed. Silicone implants, he says, do require MRI screening for leaks at 3 years after surgery and then every two years. But that screening is for leaks and not for cancer.

I had a Bilateral Mastectomy in early 2011 for my 3rd breast cancer. I had had previous radiation therapy to both sites. I had expanders put in at the time of surgery and final implants a few months later.
One implant became infected and the other had to removed due to complications. Healing on my right side took forever. My friends and family discourage me from even thinking about having breasts again because of all I went through, but in my my heart, I still want to pursue having breasts.
What do you think would be the best approach for me. I am 5'3" and weigh 145 lbs.

We are not able to answer personal questions about the best approach for your individual situation on our blog. If you'd like to make an appointment for a consultation with a specialist at MSK, you can call 800-525-2225 or go to for more information on making an appointment. Thank you for your comment.

I will be doing risk reducing mastectomy for BRCA 2 , and am interested in DIEP reconstruction only. However, about 8 years ago I had umbilical hernia repair surgery with mesh. I'd like to know if the DIEP might still be a possibility. I know a definitive answer can't be given on this site, but I am just looking for a general answer. Thank you

The best way to know for sure whether DIEP would be a possibility for your particular circumstances is to consult with one of our physicians. Please call our Physician Referral Service at 800-225-2225 to make an appointment. Thank you for reaching out to us.

BRCA2, seeking prophylactic mastectomy with DIEP reconstruction. I am hearing from other professionals (and patients) that Sloan Kettering strongly encourages implants over DIEP. Although they do DIEP, their preference is implants. Is this true? Other docs (that don't accept insurance) told me that at Sloan Kettering I will be signing consent for the doctor to do a TRAM flap if they need to while I am under anesthesia. There is no way that I want a TRAM flap and I also don't want implants. Is there any truth to what I am being told by other NYC plastic surgeons? As they say, you can't believe everything you hear. I had prophylactic BSO at Sloan and want to continue my care at Sloan.

Thanks so much for giving us the opportunity to answer your question. We reached out to Dr. Cordeiro, and this is what he and the rest of the team had to say:

"MSK surgeons have no preference for implants over DIEP flaps. In fact, we perform hundreds of microsurgical breast reconstructions annually. Our surgeons are recognized leaders in the field, lecture nationally and internationally, and have published extensively on this topic.

Each patient is assessed individually and then offered all the options for reconstruction for which they may be candidates. This is determined by the patient's expectations, cancer status and treatment, age, overall health, body type, previous surgery or radiation and other factors that impact breast reconstruction options. If the patient is a good candidate for several different options then the pros and cons of these procedures are discussed and an informed decision is made based on the patients desires and expectations.

The vast majority of patients who choose to undergo reconstruction with their abdominal tissues undergo DIEP flap reconstruction. In rare cases in which the abdominal blood vessels are small, a small portion of the muscle is included in the reconstruction. The techniques used by our surgeons have among the highest success rates reported for these procedures in the literature (over 99%) with excellent functional and cosmetic outcomes.

The bottom line is that patient's preferences are always taken into account at MSK. All patients are not the same and may or may not be ideal candidates for a DIEP flap. However, if they desire reconstruction with their own tissues a variety of other options including SGAP, gracilis, and pap flaps are available."

Do any of the plastic surgeons at Sloan Kettering perform Body Lift Perforator Flap for breast reconstruction? BRCA 2+. I have read this Body Lift is pretty new with few plastic surgeons doing this reconstruction. They basically take fat/tissue from the abdomen AND the buttock for women who don't have enough fat in either area to allow for the same cup size they had prior to surgery. Is this Body Lift Perforator Flap performed at Sloan Kettering? There is a group in New Orleans that supposedly pioneered this surgery, but I don't want to travel so far. Thanks for this website!

We do not do this procedure. Thank you for your comment.

Do Dr. Cordeiro or the other surgeons ever offer pre-pectoral implant placement after mastectomy in appropriately selected patients? I'm concerned about potential compromised function and chronic discomfort from the pectoral muscle detachment.

MSK does not currently offer this procedure to our patients. Thank you for your comment.

I am BRCA2 positive, had a prophylatic oophorectomy in 2000, took tamoxifen for 4 years, Arimidex for one, Raloxifene ever since. Am a healthy 65 year considering mastectomies and DIEP flap. It would be most helpful to know what my "odds" of breast cancer are after these interventions. How long do you expect recovery to take after the mastectomy/DIEP procedure?

Dear Marilyn, everyone's "odds" of surviving breast cancer after treatment are different and vary based on a number of factors. We would recommend that you follow up with your surgeon.

We did forward your question about recovery to Dr. Peter Cordeiro and he responded that it takes four to five days in the hospital after DIEP flap surgery and another four to eight weeks to get back to your normal lifestyle.

We hope this information is helpful and wish you all our best as you make a decision about the next steps in your care.

With a free tram, how long is it before you believe the woman would have sensation in her abdominal/belly button area and how long before she could run again? How long does it feel like she is wearing a tight belt at all times? Thank you

Dear Liz, every patient is unique and can have different experiences with regard to how quickly they heal and recover after surgery. Our patient education materials on this topic may be helpful in giving you a general sense of what to expect after this type of procedure:…. However, we would recommend that you follow up with your surgeon to discuss these and any other specific questions you may have about your particular surgery. Thank you for reaching out to us.

Hello I just had a double mastectomy and had stage one breast cancer . I have had no chemo or radiation. My expanders come out in July with breast implants. My question is it's hard enough being diagnosed with cancer and seeing the scars them to say I'm going to have more scars because I may need to do the tram or Diep flap? Is there an option for me since it's not immediate reconstruction or Nipple or skin sparring is there scarless flap from the back ? I read many horror stories about loosing sensation to the abs and back due to this surgery . How about alloderm ? Can I just have implants that will look nice without this ? I have 3 little kids at home and don't need this especially with the awful scarring and indentations , mobility might also be a factor to the back or abdominal region . Any info would be appreciated from your staff thank u

Good evening, I had a breast removed at age 40, my first mammogram, showed a lump and after further evaluation I had stage 4 breast cancer, with a tumor the size of a grapefruit. No treatment and this was 10 years ago, grateful. However, I did not have any surgery, long story. Now I am considering if I have a chance to have reconstructive surgery. Is this a option for me since it has been so long?

Dear Anne, we forwarded your inquiry to Dr. Evan Matros, a plastic surgeon at MSK, and he responded:

"Reconstruction is always a possibility, even many years after a person undergoes treatment for breast cancer. This is called delayed reconstruction, as opposed to immediate reconstruction when it is performed at the same time as a mastectomy. The two principal reconstructive options are tissue transfer or implants."

We encourage you to follow-up with your surgeon for more specific advice around possible next steps for your particular situation. Thank you for reaching out to us.

Does anyone ever have a flap procedure on one breast and an implant on the other? Or is the same type of surgery always used for both reconstructions?

Dear Carolyn, we forwarded your inquiry to Dr. Evan Matros, a plastic surgeon at MSK, and he responded:

"The goal of reconstruction using a flap is to create a fatty breast mound to more closely match the opposite breast. In general, adding an implant to the other breast would contribute to asymmetry."

Please follow up with your surgeon to discuss the best option for you. Thank you for reaching out to us.

Are you (or other hospitals) able to enhance breasts after a flap procedure has been performed. For example, if my flap procedure is completed and I'm only an A, but wishing to be a little bigger, would the surgeon then be able to put in an implant? Thank you!

Hi Kathie, according to MSK plastic surgeon Joseph Disa, we do offer this procedure, but it is best to wait about a year after the flap before placing the implant to minimize risks. Thank you for your comment.

Hello, I am a triple negative breast cancer pt. I'm preparing for a unilateral mastectomy, post lumpectomy and one re-excision due to very small area in a margin remaining positive. I currently wear a 40C; does the breast size matter when considering Diep reconstructive surgery? Or are implants preferred due to size of breast; and if so, is it better to have the implant placed above or beneath the pectoris muscle?
Thanks in advance for your response.

Dear Victoria, we sent your inquiry to Dr. Andrea Pusic, one of our plastic surgeons, and she responded:

"We can do DIEPs to match both small and large breasts - but this also depends on how much abdominal fat the patient has."

For more specific recommendations, an in person evaluation would be needed.

We hope this is helpful as you gather more information in advance of your upcoming surgery. If you would like to make an appointment with one of our specialist for a second opinion about your treatment and reconstruction options, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

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