Background <p>Implant-based breast reconstruction remains the most common reconstructive technique following mastectomy; however, long-term complications such as infection, capsular contracture, and reconstructive failure frequently necessitate implant removal. Autologous free-flap reconstruction offers a durable and definitive alternative. This study aimed to evaluate the outcomes of autologous free-flap reconstruction following failed or unsatisfactory implant-based reconstruction and to compare these results with the current literature.</p> Methods <p>A retrospective review was performed for all patients who underwent autologous free-flap salvage following failed or unsatisfactory implant-based reconstruction between 2018 and 2023 at a single high-volume microsurgical centre. Patient demographics, indications, adjuvant therapies, flap type, complications, and secondary procedures were analysed. Indications were stratified into three subgroups: capsular contracture, aesthetic and functional reconstructive complications, and implant rupture. A narrative literature review with descriptive synthesis (PubMed, Embase, Scopus, Web of Science; 2010–2025) was conducted to contextualise published outcomes, including flap survival, complications, and patient satisfaction.</p> Results <p>Sixty-six patients (mean age 53.6 years) underwent autologous free-flap salvage, representing 4.9% of all free-flap reconstructions. All cases represented elective salvage. DIEP flaps were performed in 86.4% and TUG flaps in 13.6%. Prior radiotherapy was reported in 53%. Indications included capsular contracture (69.7%), aesthetic and functional reconstructive complications (22.7%), and implant rupture (7.6%). No total flap losses occurred. Postoperative complications occurred in 7.6% of patients. Secondary procedures were performed in 55% of patients overall, with the highest rate in the capsular contracture subgroup (57%). Narrative synthesis of eight studies (814 patients, 951 flaps) demonstrated a reported flap survival rate of 98.9% across included studies. Significant improvements in patient satisfaction and psychosocial well-being have been consistently reported in the published literature following conversion to autologous reconstruction.</p> Conclusions <p>Autologous free-flap reconstruction provides a reliable and durable solution following implant failure. The combined institutional and published data support its safety and reproducibility as a definitive reconstructive strategy. Patient satisfaction and psychosocial well-being are consistently improved following conversion to autologous reconstruction, as reported in the literature.</p> Level of Evidence <p>Level III, risk / prognostic study.</p>