Implant vs. Flap Breast Reconstruction Surgery: How To Decide

Plastic and reconstructive surgeon Michelle Coriddi, MD

“Reconstruction involves multiple options, and deciding on the best one is personal,” says Dr. Coriddi (above).

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.

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 breast implants or using their own tissue, generally known as flap surgery.

At Memorial Sloan Kettering Cancer Center (MSK), 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.

MSK also has physician assistants specially trained in tattoo artistry, who create remarkably realistic 3D nipples and areolas for hundreds of patients a year. You can learn more here.

To help you better understand your choices, we spoke with MSK plastic and reconstructive surgeon Michelle Coriddi, MD.

“Reconstruction involves multiple options, and deciding on the best one is personal,” says Dr. Coriddi. “I take time with each patient to discuss all of their options and the likely outcome of each one.”

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’s Center for Advanced Reconstruction, breast surgeons who perform mastectomies, plastic surgeons who reconstruct breasts, and specialists in realistic nipple tattoos work closely with medical oncologists, radiation oncologists, and with the patients themselves to develop the best surgical treatment and breast reconstruction strategy.

The factors I consider in making recommendation to my patients include:

  • the patient’s goals in terms of their breast appearances
  • the patient’s own wises regarding the type of surgery she may want
  • the type of breast cancer  — including its location and stage of the cancer
  • body type
  • general health status
  • additional therapy potentially needed before or after surgery

What does a breast implant reconstruction procedure entail?

A breast implant is the most common form of breast reconstruction, and it involves the use of either a silicone shell filled with either saline (sterile saltwater) or silicone (gel). At MSK, we most commonly use silicone because it’s softer and feels more like a natural breast.

For many of our patients, implant surgery involves a few steps.

  1. First, at the time of mastectomy, we place a temporary tissue expander underneath or on top of the pectoralis muscle in the chest. Your surgeon will go over which approach is best for you.
  2. After a couple of weeks, once things start to heal, we slowly fill the expander in clinic with saline so that the skin — and muscle if the tissue expander is under the muscle — gradually stretch out. On average, the expansion process takes around six to eight weeks.
  3. Then, after another six to eight weeks, we remove the expander and put the final implant in its place. Before this second surgery, you will decide between a silicone- or saline-filled implant.

Is there an ideal candidate for breast implant reconstruction?

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

Implants can rupture or get infected, which may require another procedure down the line. Additionally, the U.S. Food and Drug Administration (FDA) has required monitoring silicone implants for rupture with an imaging study every few years. However, implants can provide excellent results and are a great option for many women.

Is there risk associated with breast implants and cancer?

The FDA has stated that a small number of cases of squamous cell carcinoma (SCC) had been found in the scar tissue of women with breast implants. Additionally, the FDA has stated that around 1,000 cases of breast implant-associated anaplastic large cell lymphoma have been found in association with certain textured implants. While the findings appear rare among the millions of women with implants, any new change in or around a breast implant — such as swelling, pain, a new lump, or a new rash — should be evaluated by a doctor. 

What is soft tissue flap breast reconstruction surgery?

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 (Abdominal Muscle) Breast Reconstruction

Pedicled TRAM flap reconstruction, the original method, 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.

Free DIEP and Muscle-Sparing TRAM Flap Breast Reconstruction

At MSK, our overall approach is to sacrifice the least amount of abdominal muscle possible to preserve abdominal function, and in most cases no muscle at all. We can do that using either — the free muscle-sparing TRAM flap or free DIEP flap. These procedures involve the relocation of tissue and also reconnecting 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 muscle-sparing TRAM flap, very little muscle is removed, and in DIEP flap no muscle is spared at all.

Thigh and Buttock Flap Breast Reconstruction

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.

What are the benefits of using your own tissue for breast reconstruction?

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. Additionally, it usually provides the best match with a contralateral natural breast if you are undergoing a unilateral mastectomy. With flaps, the newly reconstructed breasts tend to age the same way as a natural breast. 

What Research Has Shown

  1. Women using their own tissue report being more satisfied with their breasts than those who receive implants.
  2. Among women who received radiation after a mastectomy, the difference in satisfaction was even bigger, and women receiving their own tissue also reported fewer complications.

The choice is a very personal one that women should make in close consultation with their doctor. Every case is different. You have to have enough tissue available to donate, whether it’s from your abdomen, thigh, or buttock. For women who are too thin, implants can be a great alternative.

What are the risks or downsides to flap surgery?

It takes longer — doing a flap will often add three to six hours to a mastectomy, whereas a tissue expander 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 a weakening of the abdomen.

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 with other serious health conditions.

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 us to use a lot of the natural breast skin during reconstruction and allows women to get back to their normal life as quickly as possible. That said, we see patients at all stages, including women who have had a mastectomy without reconstruction or who underwent mastectomy at other hospitals and are now reconsidering their original decision not to have reconstruction.

Additionally, if you have had a mastectomy without reconstruction and radiation, an implant reconstruction may no longer be a good choice for you. Your surgeon will go over all options and help you decide what is best.

This story was originally published in 2022 and has been updated.