Implant vs. Flap Breast Reconstruction Surgery: How To Decide

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

Plastic and reconstructive surgeon Peter Cordeiro performs hundreds of breast reconstruction surgeries every year using both implants and skin flaps.

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 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 options, we spoke with MSK plastic and reconstructive surgeon Peter Cordeiro, 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’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 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
  • the patient’s own wishes regarding the type of surgery she may want
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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 two steps.

  1. First, at the time of mastectomy, we place a 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 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 breast implant reconstruction?

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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Is there risk associated with breast implants and cancer?

The U.S. Food and Drug Administration (FDA) has that a small number of cases of squamous cell carcinoma (SCC) had been found in the scar tissue of women with breast implants. While the finding appears 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. 

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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

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.

DIEP and Free TRAM Flap Breast Reconstruction

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.

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.

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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, 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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When is the best time for breast reconstruction — at the time of a mastectomy or afterwards?

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Watch our experts explain the best time to get breast reconstruction surgery.
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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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