Review Article|Articles in Press

Direct-to-Implant vs. Autologous Tissue Transfer: A meta-analysis of patient reported outcomes after immediate breast reconstruction.



      The effect of immediate implant and autologous breast reconstruction on patient complication rates has been studied extensively, but patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated.


      This study compares patient-reported outcomes for immediate implant reconstruction with immediate autologous reconstruction to determine advantages and disadvantages for each surgical modality from the patient’s perspective.


      A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for analysis. Meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants.


      Nineteen manuscripts were included in the analysis of breast satisfaction representing data on a total of 1,342 patients across all studies. The pooled mean of patients’ satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcome (p<0.05). The pooled mean of patients’ sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p<0.01). The pooled mean of patients’ satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p<0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study.


      Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve QoL compared to immediate reconstruction with autologous tissue transfer when both procedures are an option.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Eltahir Y.
        • Werners L.L.
        • Dreise M.
        • et al.
        Quality-of-Life Outcomes between Mastectomy Alone and Breast Reconstruction.
        Plastic and Reconstructive Surgery. 2013; 132: 201e-209e
        • Al-Ghazal S.K.
        • Sully L.
        • Fallowfield L.
        • Blamey R.W.
        The psychological impact of immediate rather than delayed breast reconstruction.
        Eur J Surg Oncol. 2000; 26: 17-19
        • Chao L.F.
        • Patel K.M.
        • Chen S.C.
        • et al.
        Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation.
        Breast Cancer Res Treat. 2014; 146: 299-308
        • Teo I.
        • Reece G.P.
        • Christie I.C.
        • et al.
        Body image and quality of life of breast cancer patients: influence of timing and stage of breast reconstruction.
        Psychooncology. 2016; 25: 1106-1112
        • Khoo A.
        • Kroll S.S.
        • Reece G.P.
        • et al.
        A comparison of resource costs of immediate and delayed breast reconstruction.
        Plast Reconstr Surg. 1998; 101: 964-970
        • Neyt M.J.
        • Blondeel P.N.
        • Morrison C.M.
        • Albrecht J.A.
        Comparing the cost of delayed and immediate autologous breast reconstruction in Belgium.
        Br J Plast Surg. 2005; 58: 493-497
        • Razdan S.
        • Cordeiro P.
        • Albornoz C.
        • et al.
        Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q.
        Plastic and Reconstructive Surgery. 2016; 137: 510e-517e
        • Pusic A.L.
        • Matros E.
        • Fine N.
        • et al.
        Patient-Reported Outcomes 1 Year After Immediate Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study.
        J Clin Oncol. 2017; 35: 2499-2506
        • Hu E.
        • Pusic A.
        • Waljee J.
        • et al.
        Patient-Reported Aesthetic Satisfaction with Breast Reconstruction during the Long-Term Survivorship Period.
        Plastic and Reconstructive Surgery. 2009; 124: 1-8
        • Yueh J.H.
        • Slavin S.A.
        • Adesiyun T.
        • et al.
        Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, and Implant Techniques.
        Plastic and Reconstructive Surgery. 2010; 125: 1585-1595
        • Albornoz C.
        • Bach P.
        • Mehrara B.
        • et al.
        A Paradigm Shift in U.S. Breast Reconstruction.
        Plastic and Reconstructive Surgery. 2013; 131: 15-23
        • Lohmander F.
        • Lagergren J.
        • Johansson H.
        • Roy P.G.
        • Frisell J.
        • Brandberg Y.
        Quality of life and patient satisfaction after implant-based breast reconstruction with or without acellular dermal matrix: randomized clinical trial.
        BJS Open. 2020; 4: 811-820
        • Kim S.E.
        • Jung D.W.
        • Chung K.J.
        • et al.
        Immediate direct-to-implant breast reconstruction using anatomical implants.
        Arch Plast Surg. 2014; 41: 529-534
        • Huang J.
        • Wang M.
        • Chagpar A.
        Factors Affecting Total Operating Time in Patients Undergoing Mastectomy With and Without Reconstruction.
        Am Surg. 2021; 87: 1107-1111
        • Naoum G.E.
        • Salama L.
        • Niemierko A.
        • et al.
        Single Stage Direct-to-Implant Breast Reconstruction Has Lower Complication Rates Than Tissue Expander and Implant and Comparable Rates to Autologous Reconstruction in Patients Receiving Postmastectomy Radiation.
        Int J Radiat Oncol Biol Phys. 2020; 106: 514-524
        • Frey J.D.
        • Choi M.
        • Salibian A.A.
        • Karp N.S.
        Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies.
        Plast Reconstr Surg. 2017; 139: 1300-1310
        • Tsoi B.
        • Ziolkowski N.I.
        • Thoma A.
        • Campbell K.
        • O'Reilly D.
        • Goeree R.
        Safety of tissue expander/implant versus autologous abdominal tissue breast reconstruction in postmastectomy breast cancer patients: a systematic review and meta-analysis.
        Plast Reconstr Surg. 2014; 133: 234-249
        • Xu F.
        • Sun H.
        • Zhang C.
        • et al.
        Comparison of surgical complication between immediate implant and autologous breast reconstruction after mastectomy: A multicenter study of 426 cases.
        J Surg Oncol. 2018; 118: 953-958
        • Pusic A.
        • Klassen A.
        • Scott A.
        • Klok J.
        • Cordeiro P.
        • Cano S.
        Development of a New Patient-Reported Outcome Measure for Breast Surgery: The BREAST-Q.
        Plastic and Reconstructive Surgery. 2009; 124: 345-353
      1. Green S. , Higgins J.P.T. Preparing a Cochrane Review. Cochrane Handbook for Systematic Reviews of Interventions: John Wiley & Sons, Ltd. p. 11-30.

        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        International Journal of Surgery. 2010; 8: 336-341
        • Min S.Y.
        • Kim H.Y.
        • Jung S.Y.
        • et al.
        Oncological safety and quality of life associated with mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap.
        Breast J. 2010; 16: 356-361
        • Winters Z.E.
        • Haviland J.
        • Balta V.
        • et al.
        Integration of patient-reported outcome measures with key clinical outcomes after immediate latissimus dorsi breast reconstruction and adjuvant treatment.
        Br J Surg. 2013; 100: 240-251
        • Freitas-Silva R.
        • Conde D.M.
        • de Freitas-Júnior R.
        • Martinez E.Z.
        Comparison of quality of life, satisfaction with surgery and shoulder-arm morbidity in breast cancer survivors submitted to breast-conserving therapy or mastectomy followed by immediate breast reconstruction.
        Clinics (Sao Paulo). 2010; 65: 781-787
      2. Veiga D.F. , Veiga-Filho J. , Ribeiro L.M. , et al. Quality-of-life and self-esteem outcomes after oncoplastic breast-conserving surgery [retracted in: J Cancer Res Ther. 2019 Jan-Mar;15(1):264]. Plast Reconstr Surg. 2010 ;125(3):811-817. doi:〈10.1097/PRS.0b013e3181ccdac5〉

        • Lee J.S.
        • Kim J.S.
        • Lee J.H.
        • et al.
        Prepectoral breast reconstruction with complete implant coverage using double-crossed acellular dermal matrixs.
        Gland Surg. 2019; 8: 748-757
        • Lai H.W.
        • Chen S.T.
        • Mok C.W.
        • et al.
        Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results.
        J Plast Reconstr Aesthet Surg. 2020; 73: 1514-1525
        • Levy J.
        • Bosc R.
        • Warren N.
        • et al.
        Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction.
        Ann Plast Surg. 2018; 80: 639-643
        • Lin I.C.
        • Bergey M.
        • Sonnad S.S.
        • Serletti J.M.
        • Wu L.C.
        Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the wise and vertical reduction patterns for mastectomy.
        Ann Plast Surg. 2013; 70: 264-270
        • Safran T.
        • Al-Halabi B.
        • Viezel-Mathieu A.
        • Boileau J.F.
        • Dionisopoulos T.
        Skin-Reducing Mastectomy with Immediate Prepectoral Reconstruction: Surgical, Aesthetic, and Patient-Reported Outcomes with and without Dermal Matrices.
        Plast Reconstr Surg. 2021; 147: 1046-1057
        • Ghilli M.
        • Mariniello M.D.
        • Camilleri V.
        • et al.
        PROMs in post-mastectomy care: Patient self-reports (BREAST-Q™) as a powerful instrument to personalize medical services.
        Eur J Surg Oncol. 2020; 46: 1034-1040
        • Manrique O.J.
        • Kapoor T.
        • Banuelos J.
        • et al.
        Single-Stage Direct-to-Implant Breast Reconstruction: A Comparison Between Subpectoral Versus Prepectoral Implant Placement.
        Ann Plast Surg. 2020; 84: 361-365
        • Caputo G.G.
        • Zingaretti N.
        • Kiprianidis I.
        • et al.
        Quality of Life and Early Functional Evaluation in Direct-to-Implant Breast Reconstruction After Mastectomy: A Comparative Study Between Prepectoral Versus Dual-Plane Reconstruction.
        Clin Breast Cancer. 2021; 21: 344-351
        • Stein M.J.
        • Karir A.
        • Arnaout A.
        • et al.
        Quality-of-Life and Surgical Outcomes for Breast Cancer Patients Treated with Therapeutic Reduction Mammoplasty Versus Mastectomy with Immediate Reconstruction.
        Ann Surg Oncol. 2020; 27: 4502-4512
        • Jeevan R.
        • Cromwell D.A.
        • Browne J.P.
        • et al.
        Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England.
        J Plast Reconstr Aesthet Surg. 2014; 67: 1333-1344
        • Dimovska E.O.F.
        • Chen C.
        • Chou H.H.
        • Lin Y.L.
        • Cheng M.H.
        Outcomes and quality of life in immediate one-stage versus two-stage breast reconstructions without an acellular dermal matrix: 17- years of experience.
        J Surg Oncol. 2021; 124: 510-520
        • Innocenti A.
        • Melita D.
        • Affortunati M.
        • Susini T.
        • Innocenti M.
        Immediate-implant-based-breast-reconstruction with two-stage expander-implant reconstruction versus one-stage-reconstruction with acellular dermal matrix: analysis of patients' satisfaction.
        Acta Biomed. 2021; 92 (Published 2021 Jul 1)e2021228
        • Qureshi A.A.
        • Odom E.B.
        • Parikh R.P.
        • Myckatyn T.M.
        • Tenenbaum M.M.
        Patient-Reported Outcomes of Aesthetics and Satisfaction in Immediate Breast Reconstruction After Nipple-Sparing Mastectomy With Implants and Fat Grafting.
        Aesthet Surg J. 2017; 37: 999-1008
        • Negenborn V.L.
        • Young-Afat D.A.
        • Dikmans R.E.G.
        • et al.
        Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial.
        Lancet Oncol. 2018; 19: 1205-1214
      3. Srinivasa D.R. , Garvey P.B. , Qi J. , et al. Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study [published correction appears in Plast Reconstr Surg. 2018 Feb;141(2):532]. Plast Reconstr Surg. 2017;140(5):869-877. doi:〈10.1097/PRS.0000000000003748〉

        • Salgarello M.
        • Visconti G.
        • Barone-Adesi L.
        • et al.
        Inverted-T skin-reducing mastectomy with immediate implant reconstruction using the submuscular-subfascial pocket.
        Plast Reconstr Surg. 2012; 130: 31-41
        • Maruccia M.
        • Elia R.
        • Gurrado A.
        • et al.
        Skin-Reducing Mastectomy and Pre-pectoral Breast Reconstruction in Large Ptotic Breasts.
        Aesthetic Plast Surg. 2020; 44: 664-672
        • Kuroda F.
        • Urban C.
        • Zucca-Matthes G.
        • et al.
        Evaluation of Aesthetic and Quality-of-Life Results after Immediate Breast Reconstruction with Definitive Form-Stable Anatomical Implants.
        Plast Reconstr Surg. 2016; 137: 278e-286e
        • Caputo G.G.
        • Vigato E.
        • Rampino Cordaro E.
        • Parodi P.C.
        • Governa M.
        Comparative study of patient outcomes between direct to implant and two-stage implant-based breast reconstruction after mastectomy.
        J Plast Reconstr Aesthet Surg. 2021; 74: 2573-2579
        • Salgarello M.
        • Pagliara D.
        • Barone Adesi L.
        • Visconti G.
        • Wild J.B.
        • Matey P.
        Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction.
        Clin Breast Cancer. 2021; 21: e454-e461
        • Spindler N.
        • Ebel F.
        • Briest S.
        • Wallochny S.
        • Langer S.
        Quality of Life After Bilateral Risk-Reducing Mastectomy and Simultaneous Reconstruction Using Pre-Pectoral Silicone Implants.
        Patient Prefer Adherence. 2021; 15 (Published 2021 Apr 13): 741-750
        • Wang S.
        • He S.
        • Zhang X.
        • et al.
        Acellular bovine pericardium matrix in immediate breast reconstruction compared with conventional implant-based breast reconstruction.
        JPRAS Open. 2021; 29 (Published 2021 Mar 27): 1-9
        • Carrasco-López C.
        • Julian Ibañez J.F.
        • Vilà J.
        • et al.
        Anterior intercostal artery perforator flap in immediate breast reconstruction: Anatomical study and clinical application.
        Microsurgery. 2017; 37: 603-610
        • Moberg I.O.
        • Schou Bredal I.
        • Schneider M.R.
        • Tønseth K.A.
        • Schlichting E.
        Complications, risk factors, and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations.
        J Plast Surg Hand Surg. 2018; 52: 234-239
        • Santosa K.B.
        • Qi J.
        • Kim H.M.
        • Hamill J.B.
        • Wilkins E.G.
        • Pusic A.L.
        Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction.
        JAMA Surg. 2018; 153: 891-899
        • Razzano S.
        • Marongiu F.
        • Wade R.
        • Figus A.
        Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes.
        Plast Reconstr Surg. 2019; 143: 261e-270e
        • Liu C.
        • Zhuang Y.
        • Momeni A.
        • et al.
        Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q.
        Breast Cancer Res Treat. 2014; 146: 117-126
        • Shammas R.L.
        • Sergesketter A.R.
        • Taskindoust M.
        • et al.
        An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.
        Ann Plast Surg. 2021; 86: S538-S544
        • Beugels J.
        • Kool M.
        • Hoekstra L.T.
        • et al.
        Quality of Life of Patients After Immediate or Delayed Autologous Breast Reconstruction: A Multicenter Study.
        Ann Plast Surg. 2018; 81: 523-527
        • Zhong T.
        • Hu J.
        • Bagher S.
        • et al.
        A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study.
        Plast Reconstr Surg. 2016; 138: 772-780
        • McCarthy C.M.
        • Mehrara B.J.
        • Long T.
        • et al.
        Chest and upper body morbidity following immediate postmastectomy breast reconstruction.
        Ann Surg Oncol. 2014; 21: 107-112
        • Jagsi R.
        • Momoh A.O.
        • Qi J.
        • et al.
        Impact of Radiotherapy on Complications and Patient-Reported Outcomes After Breast Reconstruction.
        J Natl Cancer Inst. 2018; 110: 157-165
        • Reinders F.C.J.
        • Young-Afat D.A.
        • Batenburg M.C.T.
        • et al.
        Higher reconstruction failure and less patient-reported satisfaction after post mastectomy radiotherapy with immediate implant-based breast reconstruction compared to immediate autologous breast reconstruction.
        Breast Cancer. 2020; 27: 435-444
        • Didier F.
        • Radice D.
        • Gandini S.
        • et al.
        Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality.
        Breast Cancer Res Treat. 2009; 118: 623-633
        • Bailey C.R.
        • Ogbuagu O.
        • Baltodano P.A.
        • et al.
        Quality-of-Life Outcomes Improve with Nipple-Sparing Mastectomy and Breast Reconstruction.
        Plastic and Reconstructive Surgery. 2017; 140: 219-226
        • Craft R.O.
        • Colakoglu S.
        • Curtis M.S.
        • et al.
        Patient Satisfaction in Unilateral and Bilateral Breast Reconstruction [Outcomes Article].
        Plastic and Reconstructive Surgery. 2011; 127: 1417-1424
        • Atisha D.
        • Alderman A.K.
        • Lowery J.C.
        • Kuhn L.E.
        • Davis J.
        • Wilkins E.G.
        Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study.
        Ann Surg. 2008; 247: 1019-1028
        • Santosa K.B.
        • Qi J.
        • Kim H.M.
        • Hamill J.B.
        • Wilkins E.G.
        • Pusic A.L.
        Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction.
        JAMA Surg. 2018; 153: 891-899
        • Hu E.S.
        • Pusic A.L.
        • Waljee J.F.
        • et al.
        Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period.
        Plast Reconstr Surg. 2009; 124: 1-8
        • Alderman A.K.
        • Kuhn L.E.
        • Lowery J.C.
        • Wilkins E.G.
        Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study.
        J Am Coll Surg. 2007; 204: 7-12
        • Browne J.P.
        • Jeevan R.
        • Gulliver-Clarke C.
        • Pereira J.
        • Caddy C.M.
        • van der Meulen J.H.P.
        The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer.
        Cancer. 2017; 123: 3460-3467
        • Lee C.N.
        • Pignone M.P.
        • Deal A.M.
        • et al.
        Accuracy of Predictions of Patients With Breast Cancer of Future Well-being After Immediate Breast Reconstruction.
        JAMA Surg. 2018; 153e176112
        • Sheehan J.
        • Sherman K.A.
        • Lam T.
        • Boyages J.
        Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction.
        Psychooncology. 2007; 16: 342-351
        • Snell L.
        • McCarthy C.
        • Klassen A.
        • et al.
        Clarifying the Expectations of Patients Undergoing Implant Breast Reconstruction: A Qualitative Study.
        Plastic and Reconstructive Surgery. 2010; 126: 1825-1830
        • Luan A.
        • Hui K.
        • Remington A.
        • Liu X.
        • Lee G.
        Effects of A Novel Decision Aid for Breast Reconstruction.
        Annals of Plastic Surgery. 2016; 76: S249-S254
        • Temple-Oberle C.
        • Ayeni O.
        • Webb C.
        • Bettger-Hahn M.
        • Ayeni O.
        • Mychailyshyn N.
        Shared decision-making: applying a person-centered approach to tailored breast reconstruction information provides high satisfaction across a variety of breast reconstruction options.
        J Surg Oncol. 2014; 110: 796-800
        • Zhong T.
        • Hu J.
        • Bagher S.
        • et al.
        Decision Regret following Breast Reconstruction.
        Plastic and Reconstructive Surgery. 2013; 132: 724e-734e
        • Ter Stege J.A.
        • Oldenburg H.S.A.
        • Woerdeman L.A.E.
        • et al.
        Decisional conflict in breast cancer patients considering immediate breast reconstruction.
        Breast. 2021; 55: 91-97
        • von Hippel P.T.
        The heterogeneity statistic I2 can be biased in small meta-analyses.
        BMC Medical Research Methodology. 2015; 15: 1
        • Jeevan R.
        • Browne J.P.
        • Gulliver-Clarke C.
        • et al.
        Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer.
        Plastic and Reconstructive Surgery. 2017; 139: 1036e-1045e
        • Schmidt J.L.
        • Wetzel C.M.
        • Lange K.W.
        • Heine N.
        • Ortmann O.
        Patients' experience of breast reconstruction after mastectomy and its influence on postoperative satisfaction.
        Arch Gynecol Obstet. 2017; 296: 827-834