Abstract
Background
Breast cancer is the most common female cancer. Current oncological therapies aim not only to eradicate the malignancy but also to preserve the patient’s aesthetic bodily appearance. Breast reconstruction, either with an implant or via transverse rectus abdominis myocutaneous (TRAM), is an option for immediate post-mastectomy reconstruction; however, these two operations differ in outcomes in terms of operative time, blood loss, and complications. Furthermore, the two reconstructive techniques have distinct long-term complication profiles. Implant-based reconstruction is associated with the risk of capsular contracture, whereas pedicled TRAM flap reconstruction is more prone to fat necrosis related to flap perfusion. As cosmetic satisfaction is another important factor that should be considered, this study aimed to compare surgical outcomes and patient-reported cosmetic satisfaction between immediate implant-based breast reconstruction and pedicled TRAM flap reconstruction following total mastectomy. The two types of operations were performed by a single surgeon in Rajavithi Hospital, a tertiary referral institute in Thailand.
Methods
A retrospective cohort study was conducted in female patients who underwent total mastectomy with immediate breast reconstruction between January 2018 and July 2023. Thirty patients underwent implant-based reconstruction and 30 underwent pedicled TRAM flap reconstruction. Patients with previous chest wall irradiation, neoadjuvant chemotherapy, clinical stage IV disease, or incomplete follow-up were excluded. After standardized preoperative counseling, reconstructive methods were selected based on patient preference, anatomical suitability, and clinical factors. All procedures were performed by a single breast surgeon experienced in breast surgery and reconstruction. Perioperative outcomes, postoperative complications, and patient-reported cosmetic satisfaction were compared between groups.
Results
The implant-based reconstruction group was younger than the pedicled TRAM flap reconstruction group (43.03±6.08 vs. 48.47±9.04 years, P=0.009). Compared with implant-based reconstruction, pedicled TRAM flap reconstruction was associated with longer operative time (4.78±0.77 vs. 2.45±0.83 hours, P<0.001), greater intraoperative blood loss (331.67±207.81 vs. 135.83±69.38 mL, P<0.001), and higher postoperative pain scores (7.23±1.04 vs. 4.80±1.03, P<0.001). Postoperative complication rates were comparable between groups. After adjustment for age and type of mastectomy, implant-based reconstruction remained independently associated with higher overall satisfaction [adjusted B=10.612, 95% confidence interval (CI): 1.477–19.747; P=0.02] and cosmetic satisfaction (adjusted B=13.895, 95% CI: 4.748–23.043; P=0.004).
Conclusions
Implant-based reconstruction after mastectomy was associated with shorter operative time, lower blood loss, and higher patient-reported overall and cosmetic satisfaction than pedicled TRAM flap reconstruction. However, patients in the implant-based reconstruction group were younger, which may have influenced breast shape and contour outcomes. Only minor differences in postoperative complications were observed between the groups. These findings suggest that implant-based reconstruction may be a favorable option for achieving satisfactory cosmetic outcomes and can be performed concurrently with mastectomy by a single breast surgeon.
Keywords: Implant-based reconstruction, transverse rectus abdominis myocutaneous flap (TRAM flap), total mastectomy, immediate breast reconstruction
Highlight box.
Key findings
• Comparison of outcomes and patient cosmetic satisfaction achieved after mastectomy with immediate breast reconstruction using an implant and those obtained using transverse rectus abdominis myocutaneous (TRAM) flap in a tertiary, referral hospital in Thailand, a developing country in an upper-middle-income economy. The findings of this research may differ from those reported in previous studies
What is known and what is new
• Implant-based immediate breast reconstruction was associated with several favorable perioperative outcomes compared with pedicled TRAM flap reconstruction. Specifically, implant-based reconstruction was associated with significantly shorter operative time, lower intraoperative blood loss, and reduced postoperative pain, while demonstrating a comparable postoperative complication profile. In addition, patients who underwent implant-based reconstruction reported significantly higher cosmetic satisfaction at 1 year.
• Breast cancer surgery with immediate breast reconstruction can be safely performed by a single surgeon, with favorable surgical outcomes. TRAM flap breast reconstruction using a sheath-sparing technique may reduce complications related to abdominal wall weakness.
What are the implications, and what should change now?
• In patients who are suitable candidates for both implant-based reconstruction and TRAM flap reconstruction, implant-based reconstruction may be considered the more appropriate option in light of the advantages described above. Ultimately, the final decision largely depends on the patient’s preference after having a comprehensive discussion about all relevant information.
Introduction
Breast cancer is the most common female cancer around the world (1). Current treatments aim not only to eradicate the cancer but also to maintain patients’ bodily aesthetic appearance (2,3). Although breast conservation therapy (BCT) followed by adjuvant radiotherapy is currently regarded as the standard surgical treatment for early-stage breast cancer, with survival outcomes comparable to those of mastectomy (4), a considerable proportion of patients still require total mastectomy for various clinical and patient-related reasons. These include the presence of multicentric disease, a tumor-to-breast size ratio that precludes satisfactory oncologic and cosmetic outcomes with breast conservation, diffuse suspicious or malignant-appearing microcalcifications, and patient’s preference to avoid postoperative radiotherapy (5). Consequently, mastectomy remains an essential and appropriate surgical option in the comprehensive management of breast cancer. Nowadays, patients have many modalities to choose from in order to preserve their cosmetic image after mastectomy. Immediate breast reconstruction after mastectomy is preferred over delayed reconstruction because it results in better quality of life and performs comparably with other methods in terms of disease recurrence and overall survival (6). Breast reconstruction, either with an implant or via transverse rectus abdominis myocutaneous (TRAM) flap, is an option for mastectomy reconstruction. These operations differ in terms of such outcomes as operative time, blood loss, and complications. While Implant-based reconstruction can be performed on the same incision as that of mastectomy, TRAM flap reconstruction requires another 2 incisions in order to harvest the flap and locate the new umbilical location. Furthermore, the two reconstructive techniques have distinct long-term complication profiles. Implant-based reconstruction is associated with the risk of capsular contracture, whereas TRAM flap reconstruction is more prone to fat necrosis related to flap perfusion (7,8). Finally, patient satisfaction is another important factor that should be considered for breast reconstruction.
This study aimed to compare the surgical outcomes and cosmetic satisfaction at one year after surgery achieved by immediate breast reconstruction with an implant and those obtained by pedicle TRAM flap, both of which were performed by a single surgeon in Rajavithi Hospital, a tertiary, referral institute in Thailand. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0261/rc).
Methods
Study design and setting
This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Rajavithi Hospital (No. 206/2020). Informed consent was obtained from all individual participants. A retrospective data and cohort review was conducted of 60 patients who underwent total mastectomy with immediate breast reconstruction between January 2018 and July 2023 in the Department of Surgery, Rajavithi Hospital. Patients found to have suspicious breast lesions after mammogram and ultrasound (BIRADS 4–5) underwent core needle biopsy for diagnosis of breast cancer (including ductal carcinoma in situ). The indications for total mastectomy comprised widespread disease that could not be removed by local excision with a single region or segment of breast tissue, diffuse malignant-appearing microcalcifications, patients who had contraindications for breast irradiation, and patients’ preference for mastectomy. Two types of breast reconstruction (Implant-based reconstruction and pedicle TRAM) were offered to the patient. The reconstructive procedure was selected through a shared decision-making process. All eligible patients received standardized preoperative counseling from the operating breast surgeon about both implant-based and pedicled TRAM flap reconstruction, including the benefits, limitations, and potential postoperative complications of each technique. After counseling, patients chose their preferred reconstructive method. Patient characteristics such as age, socioeconomic status, comorbidities, and disease stage were not predefined eligibility criteria for either reconstructive technique. The advantages and disadvantages of the two modalities using information from a previous study (9). Patient age, breast operation, axillary lymph node procedure: axillary dissection (ALND) or sentinel lymph node biopsy (SNLB), and definite pathologic results after surgery were recorded.
Participants
Patients who underwent total mastectomy with immediate breast reconstruction between January 2018 and July 2023 in the Department of Surgery, Rajavithi Hospital were recruited.
Exclusion criteria were patients who had previous chest wall radiation, had received neoadjuvant chemotherapy, were clinical stage IV, or could not follow up in accordance with our protocol.
Follow-up & cosmetic evaluation
All patients had followed up at 1 week, 1 month, 3 months, 6 months and 1 year postoperatively. Patient-reported overall and cosmetic satisfaction was evaluated at 1 year postoperatively, surgical wound evaluation was performed, and patient-reported overall and cosmetic satisfaction were assessed using a 5-point Likert scale.
Sample size calculation
The sample size was calculated using the formula for comparing the mean of two independent groups (10). The calculation was based on the reported mean breast satisfaction scores from the study by Dean et al. (11), with mean scores of 61.6±7.9 in the implant-based reconstruction group and 66.93±7.0 in the autologous reconstruction group. Assuming a power of 80% and a two-sided significance level of 0.05, a minimum of 32 patients per group was required.
Data collection
Data were obtained from hospital medical records, operative reports, outpatient follow-up records, and patient-reported satisfaction assessments at the 1-year postoperative visit. Thirty patients who underwent immediate implant-based reconstruction and 30 patients who underwent pedicled TRAM flap reconstruction following mastectomy were enrolled in this study. Operative time, intraoperative blood loss, total drain output, length of hospital stay, and postoperative complications were systematically recorded. The complications of primary concern included hematoma and flap necrosis. In the pedicled TRAM flap reconstruction group, both donor-site flap, recipient-site skin flap, and umbilical necrosis were evaluated. In contrast, capsular contracture was specifically assessed and recorded in the implant-based reconstruction group. At the 1-year postoperative follow-up, mammography and ultrasonography were performed to assess for implant-related complications, including capsular contracture, and autologous tissue-related complications, including fat necrosis.
Patient satisfaction assessment
Patient satisfaction was assessed using a 5-point Likert scale (1= very dissatisfied to 5= very satisfied). To facilitate interpretation and standardize the scoring scale, Likert scores were linearly transformed to a 0–100 scale using the following formula:
Transformed score = ((observed score − 1)/4) × 100
Higher scores indicate greater satisfaction. The transformed scores were used for statistical analyses and reporting.
Operative techniques
Implant-based reconstruction
For all Implant-based reconstruction, the procedures were performed in the same fashion. Nipple or skin-sparing mastectomy was conducted to preserve the skin envelope for covering the implant. With regard to the nipple-sparing technique, nipple involvement by cancer was excluded by intraoperative sub-nipple tissue frozen section. If the frozen section was positive for cancer, the nipple would be removed together with the breast tissue. After mastectomy was completed, a subpectoral plane was created at the edge of the pectoralis major muscle above the pectoralis minor muscle directly to the sternal border for coverage of the implant at the medial part. For the lateral part, the serratus anterior sheath was used for the same aim. After the lateral edge of the pectoralis major muscle and serratus anterior sheath were approximated over the implant, the patient was set in the semi-upright position to confirm equality of level, size, and ptosis of both breasts. To minimize variability related to implant characteristics, all patients in the Implant-based reconstruction group received the same prosthesis model. Specifically, a Mentor® breast implant with a round shape, moderate projection, and smooth surface was used in all cases. A Redivac drain was placed until the volume was less than 30cc before removal. Patients were able to resume normal daily activities 1 day postoperatively; however, strenuous exercise was to be avoided for at least one month.
Pedicled TRAM flap reconstruction
All patients underwent pedicled TRAM flap reconstruction using a standardized surgical technique. Skin-sparing or nipple-sparing mastectomy was performed as described for implant-based reconstruction. The ipsilateral pedicled TRAM flap, based on the superior epigastric vessels, was harvested using a sheath-sparing technique, with preservation of the rectus sheath and perforating vessels whenever feasible to minimize donor-site morbidity. After flap harvest, the anterior rectus sheath was approximated, and the donor site was reinforced with a Prolene mesh in all patients as shown in Figure 1.
Figure 1.
Sheath sparing technique for TRAM flap. TRAM, transverse rectus abdominis myocutaneous.
Before removal, two Redivac drains were placed at the chest wall underneath the flap and the abdominal wall (harvesting area) until the volume was less than 30cc. Patients were maintained on bed rest in the semi-Fowler position for the first two days postoperatively, after which gradual mobilization was encouraged, beginning with ambulation around the bedside as tolerated, depending on the level of wound discomfort. However, patients were advised to maintain a semi-Fowler position with approximately 20–30 degrees of trunk elevation for one month postoperatively to minimize excessive tension on the abdominal wall incision.
Axillary lymph node assessment of the two types of operations was performed in the same fashion. If there was no clinical lymph node involvement (identified by physical examination or imaging with mammogram and ultrasound), sentinel lymph node biopsy was performed. If the metastasis node was already proven by fine needle aspiration before surgery, or when three or more sentinel lymph nodes were positive for malignancy intraoperatively, lymph node involvement was cleared by level I–II axillary dissection.
Prophylactic antibiotics were routinely administered before surgery in all cases and continued for five days postoperatively.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics software (version 22.0; IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Shapiro-Wilk test, and descriptive data were presented as numbers, percentages, means, and standard deviation. Comparisons of demographics and clinical characteristics in the two groups were conducted using the Student’s t-test for continuous variables, while categorical variables were analyzed using the Chi-square test or Fisher’s exact test, as appropriate. Clinical outcomes between groups were analyzed using the Student’s t-test for normally distributed continuous variables and the Mann-Whitney U test for non-normally distributed data.
To reduce the potential effect of confounding, multivariable linear regression analyses were performed to evaluate the independent association between reconstruction type and patient-reported satisfaction scores and cosmetic scores. Covariates were selected based on their clinical relevance and baseline imbalance between the two groups rather than on statistical significance alone. Specifically, age was included because it differed significantly between the groups at baseline, whereas type of mastectomy was included because it was considered a clinically relevant factor that could influence postoperative patient satisfaction. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant.
Results
A total of 64 patients were assessed for eligibility. Four patients were excluded because they had received neoadjuvant chemotherapy. Consequently, 60 patients were included in the final analysis, with 30 patients in the implant-based reconstruction group and 30 patients in the pedicled TRAM flap reconstruction group. The patient selection, follow-up, and final analysis process are shown in Figure 2. Baseline demographic and clinical characteristics are summarized in Table 1. Patients in the implant-based reconstruction group were significantly younger than those in the pedicled TRAM flap group (43.0±6.1 vs. 48.5±9.0 years, P=0.009). No significant between-group differences were observed in underlying diseases, tumor type, pathological stage, or type of mastectomy.
Figure 2.
Flow diagram of patient selection and inclusion in the study. TRAM, transverse rectus abdominis myocutaneous.
Table 1. Patients’ demographic and clinical characteristics.
| Variables | Total (n=60) | Implant-based reconstruction (n=30) | Pedicled TRAM flap reconstruction (n=30) | P value |
|---|---|---|---|---|
| Age (years) | 45.75±8.11 | 43.03±6.08 | 48.47±9.04 | 0.009 |
| Underlying diseases | 0.31 | |||
| Yes | 11 (18.3) | 4 (14.3) | 7 (23.3) | |
| No | 49 (81.3) | 26 (86.7) | 24 (80.0) | |
| Specific underlying diseases | ||||
| Diabetes mellitus | 2 (3.3) | 1 (3.3) | 1 (3.3) | >0.99 |
| Hypertension | 3 (5.0) | 1 (3.3) | 2 (6.7) | >0.99 |
| Dyslipidemia | 2 (3.3) | 0 (0.0) | 2 (6.7) | 0.49 |
| Thalassemia | 2 (3.3) | 1 (3.3) | 1 (3.3) | >0.99 |
| Tumor type | 0.69 | |||
| IDC | 45 (75.0) | 24 (80.0) | 21 (70.0) | |
| DCIS | 9 (15.0) | 4 (13.3) | 5 (16.7) | |
| Others | 6 (10.0) | 2 (6.7) | 4 (13.3) | |
| Pathological stage | 0.88 | |||
| DCIS | 6 (10.2) | 3 (10.3) | 3 (10.3) | |
| 1 | 12 (20.3) | 7 (23.3) | 5 (17.2) | |
| 2 | 31 (52.5) | 16 (53.3) | 15 (51.7) | |
| 3 | 10 (16.9) | 4 (13.3) | 6 (20.7) | |
| Type of mastectomy | 0.19 | |||
| Modified radical mastectomy (sentinel lymph node-positive or clinically node-positive) | 33 (55.0) | 14 (46.7) | 19 (63.3) | |
| Total mastectomy | 27 (45.0) | 16 (53.3) | 11 (36.7) |
Data are presented as mean ± standard deviation or n (%). DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; TRAM, transverse rectus abdominis myocutaneous.
Perioperative outcomes are presented in Table 2. Compared with the pedicled TRAM flap group, the implant-based reconstruction group had a significantly shorter operative time (2.45±0.83 vs. 4.78±0.77 hours; mean difference, −2.33 hours; 95% CI: −2.75 to −1.91; P<0.001), lower intraoperative blood loss (135.83±69.38 vs. 331.67±207.81 mL; mean difference, −195.84 mL; 95% CI: −280.15 to −111.52; P<0.001), and lower postoperative pain scores (4.80±1.03 vs. 7.23±1.04; mean difference, −2.43; 95% CI: −2.95 to −1.91; P<0.001). There were no significant differences in length of hospital stay, total drainage volume, or overall postoperative complication rates between the two groups.
Table 2. Comparison of clinical outcomes between implant-based and pedicled TRAM flap breast reconstruction.
| Characteristics | Implant-based reconstruction (n=30) | Pedicled TRAM flap reconstruction (n=30) | Mean difference (95% CI) | P value |
|---|---|---|---|---|
| Operative time (hours) | 2.45±0.83 | 4.78±0.77 | −2.33 (−2.75 to −1.91) | <0.001 |
| Blood loss (mL) | 135.83±69.38 | 331.67±207.81 | −195.84 (−280.15 to −111.52) | <0.001 |
| Length of hospital stay (days) | 7.76±2.27 | 9.33±6.62 | −1.57 (−4.09 to 0.95) | 0.22 |
| Postoperative pain score (0–10) | 4.80±1.03 | 7.23±1.04 | −2.43 (−2.95 to −1.91) | <0.001 |
| Total drainage volume (mL) | 367.83±261.44 | 479.40±169.61 | −111.57 (−225.46 to 2.33) | 0.055 |
| Complications | 6 (20.0) | 7 (23.3) | – | 0.75 |
| Hematoma | 1 (3.3) | 1 (3.3) | – | – |
| Skin or nipple-sparing necrosis | 1 (3.3) | 2 (6.7) | – | – |
| TRAM flap necrosis | 0 (0.0) | 4 (13.3) | – | – |
| Capsular contracture | 3 (10.0) | 0 (0.0) | – | – |
Data are presented as mean ± standard deviation or n (%). All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. CI, confidence interval; TRAM, transverse rectus abdominis myocutaneous.
Overall and cosmetic patient-reported satisfaction were assessed at the 1-year follow-up (Tables 3,4). The implant-based reconstruction group had higher overall satisfaction scores than the pedicled TRAM flap reconstruction group (90.8±13.9 vs. 81.7±18.5 on the 0–100 scale; mean difference, 9.17 points; 95% CI: 0.71–17.62; P=0.03). Similarly, cosmetic satisfaction scores were higher in the implant-based reconstruction group compared with the pedicled TRAM flap reconstruction group (78.3±17.0 vs. 62.5±15.7 on the 0–100 scale; mean difference, 15.83 points; 95% CI: 7.36–24.31; P<0.001).
Table 3. Comparison of overall satisfaction scores between implant-based and pedicled TRAM flap breast reconstruction.
| Satisfaction | Implant-based reconstruction (n=30) | Pedicled TRAM flap reconstruction (n=30) | Mean difference (95% CI) | P value |
|---|---|---|---|---|
| Overall satisfaction score (0–100 scale) | 90.8±13.9 | 81.7±18.5 | 9.17 (0.71 to 17.62) | 0.03 |
| Likert scale categories | ||||
| 5 (extremely satisfied) | 20 (66.7) | 13 (43.3) | – | – |
| 4 (very satisfied) | 9 (30.0) | 12 (40.0) | – | – |
| 3 (satisfied) | 1 (3.3) | 5 (16.7) | – | – |
| 2 (not satisfied) | 0 (0.0) | 0 (0.0) | – | – |
| 1 (extremely dissatisfied) | 0 (0.0) | 0 (0.0) | – | – |
Data are presented as mean ± standard deviation or n (%). Satisfaction scores were assessed using a 5-point Likert scale and transformed to a 0–100 scale for analysis, with higher scores indicating greater satisfaction. Mean differences represent implant-based reconstruction minus pedicled TRAM flap reconstruction. A two-sided P value <0.05 was considered statistically significant. CI, confidence interval; TRAM, transverse rectus abdominis myocutaneous.
Table 4. Comparison of cosmetic satisfaction between implant-based and pedicled TRAM flap reconstruction.
| Cosmetic satisfaction | Implant-based reconstruction (n=30) | Pedicled TRAM flap reconstruction (n=30) | Mean difference (95% CI) | P value |
|---|---|---|---|---|
| Cosmetic satisfaction score (0–100 scale) | 78.3±17.0 | 62.5±15.7 | 15.83 (7.36 to 24.31) | <0.001 |
| Likert scale categories | ||||
| 5 (extremely satisfied) | 9 (30.0) | 2 (6.7) | – | – |
| 4 (very satisfied) | 16 (53.3) | 11 (36.7) | – | – |
| 3 (satisfied) | 5 (16.7) | 17 (56.7) | – | – |
| 2 (not satisfied) | 0 (0.0) | 0 (0.0) | – | – |
| 1 (extremely dissatisfied) | 0 (0.0) | 0 (0.0) | – | – |
Data are presented as mean ± standard deviation or n (%). Cosmetic satisfaction scores were assessed using a 5-point Likert scale and transformed to a 0–100 scale for analysis, with higher scores indicating greater satisfaction. Mean differences represent implant-based reconstruction minus pedicled TRAM flap reconstruction. A two-sided P value <0.05 was considered statistically significant. CI, confidence interval; TRAM, transverse rectus abdominis myocutaneous.
Multivariable linear regression analyses were performed to evaluate factors associated with overall and cosmetic patient-reported satisfaction. Age, type of mastectomy, and type of reconstruction were entered as independent variables in each model. Implant-based reconstruction was independently associated with higher overall satisfaction scores (adjusted B=10.612, 95% CI: 1.477–19.747; P=0.02), whereas age and type of mastectomy were not significantly associated with overall satisfaction (Table 5). Similarly, implant-based reconstruction was independently associated with higher cosmetic satisfaction scores (adjusted B=13.895, 95% CI: 4.748–23.043; P=0.004), whereas age and type of mastectomy were not significantly associated with cosmetic satisfaction (Table 6). Representative postoperative clinical photographs demonstrating implant-based reconstruction and TRAM flap reconstruction are presented in Figures 3,4, respectively, for illustrative purposes only and were not included in the quantitative analysis.
Table 5. Multivariable linear regression analysis of factors associated with overall satisfaction scores after breast reconstruction.
| Variable | Adjusted B | 95% CI | P value |
|---|---|---|---|
| Implant-based reconstruction vs. pedicled TRAM flap reconstruction | 10.612 | 1.477 to 19.747 | 0.02 |
| Age (years) | 0.319 | −0.242 to 0.880 | 0.26 |
| Type of mastectomy | 1.742 | −6.928 to 10.412 | 0.69 |
CI, confidence interval. Adjusted B represents the unstandardized regression coefficient from the multivariable linear regression model. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. CI, confidence interval; TRAM, transverse rectus abdominis myocutaneous.
Table 6. Multivariable linear regression analysis of factors associated with cosmetic satisfaction scores after breast reconstruction.
| Variable | Adjusted B | 95% CI | P value |
|---|---|---|---|
| Implant-based reconstruction vs. pedicled TRAM flap reconstruction | 13.895 | 4.748 to 23.043 | 0.004 |
| Age (years) | −0.234 | −0.796 to 0.328 | 0.41 |
| Type of mastectomy | 4.008 | −4.675 to 12.690 | 0.36 |
Adjusted B represents the unstandardized regression coefficient from the multivariable linear regression model. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. CI, confidence interval; TRAM, transverse rectus abdominis myocutaneous.
Figure 3.
Immediate breast reconstruction with implant after nipple-sparing mastectomy.
Figure 4.
Immediate breast reconstruction with transverse rectus abdominis myocutaneous flap.
Discussion
Breast cancer remains the most common female cancer around the world (1), with the number of affected patients increasing every year. Even though surgery is the main treatment for breast cancer, nowadays we have to be concerned not only with complete cancer cure but also with the bodily appearance of the patients. Currently, mastectomy is still the standard of care for breast cancer patients who cannot undergo BCT; however, breast reconstruction following mastectomy plays a crucial role in restoring the body image and improving the psychological well-being of these patients. Both implant-based and autologous reconstruction using the TRAM flap are well-established techniques, each with its distinct advantages and limitations. In this retrospective cohort study conducted at Rajavithi Hospital, a tertiary, referral institute in Thailand, we found that implant-based reconstruction was associated with significantly shorter operative time, lower intraoperative blood loss, and reduced postoperative pain. Furthermore, cosmetic satisfaction assessed at the 1-year follow-up appeared to be higher among patients who underwent implant-based reconstruction than among those who underwent pedicled TRAM flap reconstruction. These findings highlight the feasibility and effectiveness of Implant-based reconstruction as an immediate reconstructive option following mastectomy.
Our results demonstrated that operative time in the Implant-based reconstruction group was significantly shorter than in the TRAM flap group. This finding is consistent with those of previous studies (12) which reported that implant-based reconstruction is technically less complex and does not require flap harvesting or microvascular manipulation, thereby reducing operative duration. In contrast, TRAM flap reconstruction involves flap elevation, preservation of vascular pedicles, abdominal wall repair, additional donor-site closure, and relocation of the umbilicus, all of which contribute to longer operative time (13).
In addition to operative time, intraoperative blood loss was significantly lower in the Implant-based reconstruction group compared with the TRAM flap group. This difference was to be expected due to the more extensive dissection required for TRAM flap harvesting, including muscle and soft tissue mobilization. Lower blood loss may reduce perioperative morbidity and the need for blood transfusion, which can be particularly beneficial for patients with comorbidities or limited physiological reserve.
Postoperative pain scores were also significantly lower in patients undergoing Implant-based reconstruction group. This difference is probably attributable to the absence of donor-site pain in Implant-based reconstruction. TRAM flap reconstruction involves abdominal wall dissection, which may lead to increased postoperative pain, delayed mobilization, and longer recovery time. Donor-site morbidity, such as abdominal laxity or incisional hernia, has been widely recognized as a major disadvantage of autologous reconstruction techniques, and it may negatively affect early postoperative recovery and patient comfort (14). However, these complications were not observed in the present study, probably because of the consistent use of the sheath-sparing technique in all cases. Moreover, a Prolene mesh was routinely placed on top of the rectus sheath to reinforce the abdominal wall, thereby enhancing structural integrity and reducing the risk of abdominal wall morbidity.
Interestingly, our cohort study demonstrated significantly higher cosmetic satisfaction in the Implant-based reconstruction group than in the TRAM flap group at 1 year follow up. Although autologous reconstruction is often considered the gold standard for achieving natural breast contour and long-term aesthetic outcomes, several factors may explain our findings. First, implant reconstruction was performed immediately after mastectomy using skin- or nipple-sparing techniques, which preserve the breast envelope and enhance aesthetic appearance. Second, implant reconstruction avoids abdominal donor-site scarring and contour deformity, which may influence patients’ overall perception of cosmetic results. Previous studies have reported inconsistent findings, with some reporting equal cosmetic satisfaction with the two procedures, whereas others have found that the TRAM flap was better (15,16). Although several systematic reviews have compared implant-based reconstruction with autologous breast reconstruction as a whole, the autologous group generally combines DIEP, free TRAM, pedicled TRAM, and other flap techniques. Consequently, evidence specifically comparing implant-based reconstruction with pedicled TRAM flap reconstruction remains limited, particularly in low- and middle-income countries where pedicled TRAM remains the predominant autologous option. Another important difference in this study is the relatively short follow-up period of only one year for the assessment of patient satisfaction. Implant-related complications, particularly capsular contracture and implant failure, are known to increase over time. Therefore, the one-year follow-up in our study may underestimate the true incidence of these long-term complications and their impact on patient-reported satisfaction. In contrast, several systematic reviews have included studies with substantially longer follow-up periods, allowing the cumulative effects of implant-related complications to become more apparent. Consequently, autologous reconstruction, including TRAM flap reconstruction, may demonstrate greater patient satisfaction than implant-based reconstruction over longer-term follow-up (17).
Regarding complications, both reconstruction techniques demonstrated acceptable safety profiles. There were no major complications requiring implant removal or total flap loss in either group. Partial TRAM flap necrosis occurred in four patients (13.3%) in this cohort, which is comparable to findings reported in previous studies (18). All cases were diagnosed through clinical assessment, supported by mammographic and ultrasonographic findings, at the one-year follow-up. None of the affected patients required flap removal, and all cases were successfully managed by conservative treatment with acceptable cosmetic results. Similarly, grade II capsular contracture was observed in three patients in the implant group (10%), and the most common cause was postoperative radiation (19); however, the capsular contracture rate in this study was relatively low compared with incidence rates reported in previous research (20). Despite these complications, the overall cosmetic outcomes were considered acceptable, and patient satisfaction levels remained favorable. Capsular contracture in the implant group was managed conservatively with no significant impact on overall outcomes. These findings support the belief that immediate breast reconstruction together with mastectomy is safe when performed by an experienced breast surgeon. The relatively low complication rates observed in this study may also be attributed to careful patient selection, standardized surgical techniques, and consistent postoperative follow-up.
Our findings align with those reported in previous studies in the literature which have suggested that implant-based reconstruction offers advantages in terms of operative efficiency, reduced morbidity, and acceptable cosmetic outcomes, particularly in appropriately selected patients (21). However, autologous reconstruction using pedicle TRAM flap remains an important option, especially in patients with contraindications to implants, inadequate skin envelope, severe breast ptosis, or those who prefer autologous tissue reconstruction. Autologous reconstruction may also provide superior long-term durability and avoid implant-related complications such as capsular contracture, implant rupture, or implant infection (22).
The association between implant-based reconstruction and higher patient satisfaction remained statistically significant after adjustment for clinically relevant covariates, including age and type of mastectomy. This finding indicates that the observed association remained statistically significant after adjustment for these measured covariates. Nevertheless, because of the retrospective observational design, residual confounding from unmeasured variables cannot be excluded. Therefore, our findings should be interpreted as indicating an independent association, rather than evidence of a causal relationship or the overall superiority of implant-based reconstruction over pedicled TRAM flap reconstruction.
This study had several limitations. The retrospective design may have introduced selection bias because reconstruction type was not randomly assigned. The sample size was estimated using BREAST-Q satisfaction data because no published study using the same 5-point Likert satisfaction scale was available at the time of study design. Therefore, the sample size estimation should be interpreted with caution because it was based on a different measurement instrument. Patient satisfaction was assessed using a 5-point Likert scale. Although the scores were linearly transformed to a 0–100 scale to facilitate comparison with previous studies, they should not be interpreted as equivalent to BREAST-Q scores. In addition, only 30 patients were included in each group, slightly fewer than the planned sample size, which may have reduced statistical power and limited the generalizability of the findings. Finally, the 1-year follow-up period may not fully capture long-term patient satisfaction or delayed implant- or flap-related complications. Therefore, these findings should be interpreted as short-term patient-reported outcomes, and longer follow-up studies are needed to evaluate the durability of reconstructive outcomes.
From a clinical perspective, these findings suggest that implant-based reconstruction may be considered for selected patients who prioritize shorter operative time and favorable short-term patient-reported outcomes at the 1-year follow-up. Nevertheless, the choice of reconstructive technique should remain individualized, taking into account patient preferences, anatomical characteristics, comorbidities, previous treatments, and surgeon expertise through a shared decision-making process.
Despite these limitations, this study provides valuable comparative data on perioperative outcomes and patient satisfaction following immediate implant-based and pedicled TRAM flap reconstruction in a tertiary referral center in Thailand. Within the limitations of this study, implant-based reconstruction was associated with lower operative morbidity and higher patient satisfaction than pedicled TRAM flap reconstruction.
Future prospective multicenter studies with larger sample sizes, longer follow-up, and standardized patient-reported outcome measures are warranted to confirm these findings and determine whether the observed short-term benefits translate into improved long-term reconstructive outcomes.
Conclusions
In this retrospective cohort study conducted at a tertiary referral center, implant-based immediate breast reconstruction was associated with several favorable perioperative outcomes compared with pedicled TRAM flap reconstruction. Specifically, implant-based reconstruction was associated with significantly shorter operative time, lower intraoperative blood loss, and reduced postoperative pain, while demonstrating a comparable postoperative complication profile. In addition, patients who underwent implant-based reconstruction reported significantly higher cosmetic satisfaction at the 1-year follow-up.
Although autologous reconstruction with pedicled TRAM flap remains an important option for selected patients, particularly those who prefer autologous tissue reconstruction or have contraindications for implants, our findings suggest that implant-based reconstruction is an effective and cosmetically favorable approach for immediate breast reconstruction following mastectomy. Finally, immediate breast reconstruction performed by an experienced breast surgeon can be safely integrated into oncologic surgery and plays an important role in restoring bodily appearance and improving postoperative quality of life among patients with breast cancer.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Rajavithi Hospital (No. 206/2020). Informed consent was obtained from all individual participants.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0261/rc
Funding: This study was supported by Rajavithi Hospital (No. 63182).
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0261/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0261/dss
References
- 1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63.. 10.3322/caac.21834 [DOI] [PubMed] [Google Scholar]
- 2. Lee GK, Sheckter CC. Breast Reconstruction Following Breast Cancer Treatment-2018. JAMA 2018;320:1277-8.. 10.1001/jama.2018.12190 [DOI] [PubMed] [Google Scholar]
- 3. Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002;109:2265-74.. 10.1097/00006534-200206000-00015 [DOI] [PubMed] [Google Scholar]
- 4. McGuire KP, Santillan AA, Kaur P, et al. Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol 2009;16:2682-90.. 10.1245/s10434-009-0635-x [DOI] [PubMed] [Google Scholar]
- 5.National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Breast cancer. Version 1.2026. Plymouth Meeting (PA): National Comprehensive Cancer Network; 2026.
- 6. Yoon AP, Qi J, Brown DL, et al. Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study. Breast 2018;37:72-9.. 10.1016/j.breast.2017.10.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Lee SB, Lee JW, Kim HJ, et al. Long-term outcomes of patients with breast cancer after nipple-sparing mastectomy/skin-sparing mastectomy followed by immediate transverse rectus abdominis musculocutaneous flap reconstruction: Comparison with conventional mastectomy in a single center study. Medicine (Baltimore) 2018;97:e0680.. 10.1097/MD.0000000000010680 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Lam TC, Hsieh F, Salinas J, et al. Immediate and Long-term Complications of Direct-to-implant Breast Reconstruction after Nipple- or Skin-sparing Mastectomy. Plast Reconstr Surg Glob Open 2018;6:e1977.. 10.1097/GOX.0000000000001977 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Ilonzo N, Tsang A, Tsantes S, et al. Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes. Breast 2017;32:7-12.. 10.1016/j.breast.2016.11.023 [DOI] [PubMed] [Google Scholar]
- 10.Bernard R. Fundamentals of biostatistics. 5thed: Duxbury Press; 2000. [Google Scholar]
- 11. Dean NR, Crittenden T. A five year experience of measuring clinical effectiveness in a breast reconstruction service using the BREAST-Q patient reported outcomes measure: A cohort study. J Plast Reconstr Aesthet Surg 2016;69:1469-77.. 10.1016/j.bjps.2016.08.015 [DOI] [PubMed] [Google Scholar]
- 12. Tondu T, Tjalma WAA, Thiessen FEF. Breast reconstruction after mastectomy. Eur J Obstet Gynecol Reprod Biol 2018;230:228-32.. 10.1016/j.ejogrb.2018.04.016 [DOI] [PubMed] [Google Scholar]
- 13. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free. J Surg Oncol 2006;94:532-7.. 10.1002/jso.20492 [DOI] [PubMed] [Google Scholar]
- 14. Wang XL, Liu LB, Song FM, et al. Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction. Aesthetic Plast Surg 2014;38:681-91.. 10.1007/s00266-014-0333-3 [DOI] [PubMed] [Google Scholar]
- 15. Spear SL, Newman MK, Bedford MS, et al. A retrospective analysis of outcomes using three common methods for immediate breast reconstruction. Plast Reconstr Surg 2008;122:340-7.. 10.1097/PRS.0b013e31817d6009 [DOI] [PubMed] [Google Scholar]
- 16. Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010;125:1585-95.. 10.1097/PRS.0b013e3181cb6351 [DOI] [PubMed] [Google Scholar]
- 17. Stefura T, Rusinek J, Wątor J, et al. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J Plast Reconstr Aesthet Surg 2023;77:346-58.. 10.1016/j.bjps.2022.11.044 [DOI] [PubMed] [Google Scholar]
- 18. Scheer AS, Novak CB, Neligan PC, et al. Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg 2006;56:355-8.. 10.1097/01.sap.0000201549.83738.42 [DOI] [PubMed] [Google Scholar]
- 19. Momoh AO, Ahmed R, Kelley BP, et al. A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy. Ann Surg Oncol 2014;21:118-24.. 10.1245/s10434-013-3284-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Rocco N, Catanuto GF, Accardo G, et al. Implants versus autologous tissue flaps for breast reconstruction following mastectomy. Cochrane Database Syst Rev 2024;10:CD013821.. 10.1002/14651858.CD013821.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. de Boniface J, Coudé Adam H, Frisell A, et al. Long-term outcomes of implant-based immediate breast reconstruction with and without radiotherapy: a population-based study. Br J Surg 2022;109:1107-15.. 10.1093/bjs/znac283 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Knox ADC, Ho AL, Leung L, et al. Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review. Plast Reconstr Surg 2016;138:16-28.. 10.1097/PRS.0000000000001747 [DOI] [PubMed] [Google Scholar]