Deciding between Implant and Flap Surgery

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

Peter Cordeiro, Chief of the Plastic and Reconstructive Surgical Service

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?

VIDEO | 01:06
Watch our experts explain the best time to get breast reconstruction surgery.
Video Details

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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Commenting is disabled for this blog post.

I had mastectomy on left breast and reduction with lift on the right in 2015. I had radiation which really made my skin tight and thin. I ended up doing the expander with implant. The pulling and tightness is becoming annoying and I’m thinking about the Diep flap. Have other women who had elected implants, down the road choose this procedure? Can it be done? Thank you.

I've had unilateral mastectomy due to DCIS, and 3 months later I still have a seroma, about 70cc every week aspirated. I am obese . What is the way to end these endless refills? Another surgery?

Hello , I just had an lumpectomy I have dcis well they didn’t get it all so another surgery is planned so now my breast will be indented . I was thinking of removing my breasts and doing the flap but if I do that do I do the radiation for four weeks that I’m suppose to do then do the the flap or don’t do the radiation . I’m suppose take a pill after that for five years

I recently read an abstract which studied women who had delayed breast reconstruction. It concluded that surgery in itself sometimes encouraged dormant cancer cells to be stimulated and cause the cancer to recurr at a 2
year and 6 years after surgery. I am considering having delayed reconstruction and want to make an informed decision. Do your doctors believe this to be a true and accepted hypothesis?

Dear Catherine, we sent you question to our breast cancer reconstruction team and this was their response:

Thank you for your question. Curing and treating cancer is the primary goal of everyone involved in breast cancer patient’s care at MSK. After mastectomy to treat breast cancer, reconstruction is a well established technique that helps a patient feel whole again and improve the psychosocial aspect of life after breast cancer. Given the primary concern of treating cancer, it is of primary importance that the reconstruction in no way leads to an increase in breast cancer. In many ways, after all, breast reconstruction is elective.

We have previously examined the risk of breast cancer recurrence in patients who underwent breast reconstruction at MSK. In 2008, we published a study examining 618 patients who underwent mastectomy for invasive cancer, half of which underwent reconstruction with implant based techniques. There was no difference in the incidence of locoregional recurrence comparing these groups of women (6.8% risk for reconstruction, 8.1% risk for mastectomy only, p=0.6) (McCarthy CM 2008). We then also examined cancer recurrence in a cohort of autologous (tissue based) breast reconstruction patients, and found an incidence less than 5% with an average of 5 years of follow up (Howard 2006). Additional studies in immediate breast reconstruction patients also found low risk (Speigel AJ 2003, Langstein 2003). Several recent European studies have also demonstrated no increased risk specifically in delayed breast reconstruction patients. (Dillekas 2016, Adam 2018). However, it is important to understand that the European studies may not be directly applicable to the US population.

Given the available literature and our current clinical practice, we believe that the data demonstrates that breast reconstruction does not increase risk of cancer recurrence after mastectomy. This is however certainly an issue that we continue to monitor and study as it is of utmost importance to our breast cancer patients.

Here are links to the relevant studies:

Thank you for your comment, and best wishes to you.

I am a former colon cancer patient treated at MSKCC. I have read there is a correlation between colon cancer patients who develop breast cancer later on. I have breast implants currently which are capsulized and placed 15 years ago. Given my positive experience at MSKCC for colon cancer, I would feel most comfortable having these implants removed and discussing the DIEP Flap procedure. I do not currently have breast cancer but could I meet with a surgeon at MSKCC to discuss options to have the procedure done there?

Hi! I am a thin and slim woman who is a BRCA1 gene mutation carrier. I will be having a preventative double mastectomy and I am looking to have reconstruction using my own tissue/fat etc. I have had liposuction on my legs and buttocks three times to treat pre-stage 1. As a result of these procedures, I now have a LOT of loose skin around my thighs and buttocks. I have seen surgeons about dealing with this and they all say the most effective method would be to perform a buttocks or leg lift, pulling the skin up. I was wondering if there is any way to determine if I would have enough skin to reconstruct my new boobs? I am slim, but I still do have fat and loose skin so I would love an expert to help me out. Many thanks!

I had a unilateral mastectomy in 2007 with implant reconstruction. Thinking about diet flap. I will speak to my doctor but I was wondering if I have a diet flap my reconstructed Breast will not grow if I gain weight will it. This may sound vain but I’m curious. Would an implant to make it slightly bigger to match my real Breast be something that could be placed in my new tummy fat Breast?

I am considering DIEP post bilateral mastectomy. While I would prefer immediate reconstruction, my case is complicated by my smoking history. I have eliminated all nicotine for 2 weeks with surgery in 2 weeks = 4 nicotine free. Would a delayed reconstruction, allowing extra time post nicotine, improve my odds of success? What is your definition of ex- smoker in terms of plastic surgery? Thanks.

Dear Allyson, we are not able to make treatment recommendations on our blog. If you’d like to arrange a consultation with a surgeon at MSK to learn about your options for reconstruction, you can make an appointment online or call 800-525-2225 to learn more. Thank you for your comment and best wishes to you.

I have some general questions that I hope someone can answer:
1) For women who have tissue expanders (and then later have implants) at the same time as mastectomy surgery, what percentage have immediate or later medical complications such as infection, leaking implants, immune issues etc.?
2) For the tissue flap (DIEP) surgery, what percentage of women have tissue flaps that don't "take"? What percentage have infection?
3) In what percentage of DIEP surgeries do the surgeons end up needing to take (even a small amount) of abdominal muscle?
Thank you!

Dear Rose, you may find this information helpful. We recommend that you also discuss this with a surgeon. Thank you for your comment and best wishes to you.

I had bilateral mastectomy in 2003. Saline implants. Honestly I have never been happy with them. I am interested in having the DIEP Flap. I want the best place to go to so I can feel like a woman again. I haven’t had these replaced since 2003. They don’t look or feel normal at all. How difficult would this be to have done?