There are many options for breast reconstruction, and some women are candidates for every option, and some are candidates for only a few depending on their bodies.
Implant-based reconstruction has the advantages of being faster in terms of the actual surgical time as well as technically easier for the Plastic Surgeon. Recovery is faster as well. It will require the placement of a tissue expander in the first stage of reconstruction which will then be expanded in the doctor’s office over the course of 6-8 weeks. Once the expander is full, you are taken back to the operating room for an exchange of the expander for the permanent gel implant. Nipple and areola are reconstructed at a later time after this second surgery.
A DIEP flap is much more technically demanding. Preparing the flap requires a high degree of surgical expertise because it involves removing abdominal skin and fat attached to a single artery and vein that emerge from the abdominal muscles. The muscles themselves are left intact. The area on your chest that will receive the flap also must be prepared by locating a small artery and vein that run along the inside of your rib cage. Once both are ready, the flap is sutured into place using microsurgical technique (a large operating microscope is used to magnify the small blood vessels up to 40x). This surgery will take much longer than placing an expander, and it is much more difficult.
So to answer your question, who is most satisfied? Studies are showing (and anecdotally, my patients tend to agree), that breast reconstruction using your own tissues (also known as autologous) results in longer-lasting results with greater satisfaction than implant-based reconstruction. This is because the newly created breast is made from your own tissues and looks and feels like a real breast. The flap can be molded appropriately to shape the breast nicely. And just as important, a flap will not need to be replaced or fail in 10-15 years. It is permanent.
Implant-based breast reconstruction, despite being easier, faster, and a quicker recovery, places a foreign body (the implant) to recreate your breast. Some women complain that the implant does not feel natural and does not look natural. It is more difficult to mold and shape a breast that is recreated from an implant. And finally, all implants will fail at some point. This might present as a contracture (scar tissue) around the implant or a rupture of the implant. Which means you will need to have further revision surgery in the future if these things become clinically significant.
That being said, both options are still widely accepted and both options can create beautiful results. In fact, the vast majority of breast reconstructions being performed in the United States are still implant-based. I perform both, and I have extensive experience with the DIEP flap and microsurgery.