Why Investigate Implant Upsizing in a Mastectomy Skin Flap Necrosis Study?

Lisa Cassileth, MD, FACS, chief executive officer and founder of The Practice Healthcare, discussed the origins of her retrospective study on breast implant sizing, which was published in Aesthetic Surgery Journal Open Forum. For years, a common clinical assumption held that increasing implant size beyond the mastectomy specimen size was unsafe, prompting many surgeons to default to smaller implants or staged tissue expanders. Cassileth and colleagues set out to test that assumption directly by comparing complication rates between patients who received larger implants, the upsize group, and those who received smaller implants, the downsize group, during direct-to-implant reconstruction. She explained what drove her team to formally investigate whether upsizing carries the risk it is often assumed to.

Transcript:

CancerNetwork: What clinical assumptions or institutional protocols prompted you to evaluate whether implant upsizing impacts mastectomy skin flap necrosis?

Cassileth: What prompted me was this frequent standard I’d hear, not just from other doctors but also from patients, that you can’t upsize the breast to a bigger implant because it wasn’t safe and would cause harm to the patient. The question is, is that true? Because if it is true, you shouldn’t be doing it, but if it’s not true, you should know that. There was this automatic, knee-jerk [assumption] that doctors would have to place a tissue expander or a smaller implant because it was dangerous to upsize the patient. If that wasn’t true, why would they think that, and how could we correct that line of thinking? We set out to reflect what we were seeing clinically, which was whether it was a danger to patients. Our result was that, strangely, not only was it not a danger to patients, but the patients undergoing upsizing had a lower complication rate than those undergoing a smaller implant compared to the mastectomy flap size.

Reference

Cassileth LB, Killeen KL, York A, Rosen D. Does breast implant size larger than mastectomy specimen size increase the risk of flap necrosis? Aesthet Surg J Open Forum. 2026;8:ojag063. doi:10.1093/asjof/ojag063