BREAST IMPLANT SIZING 101
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Divecat & Calico, I had a BMX with permanent implants and received 800 cc implants. This kind of surgery is not only for small implants. The surgeon needs to leave a large enough flap for the PS to work with, however.
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sandra...were you going much bigger than you naturally were with your direct to implant though?
Because calico has said she is small breasted and wants to go bigger than she currently is....so yes, having a large enough skin/tissue flap...even if the surgeon left as much as he could and used Allodem...there would be a concern in accommodating an implant that would allow her to be bigger than she currently is. My concern is that when her doctor says "it depends on her morphology" is that she WILL be disappointed when she wakes up because her small breasts won't leave much of a pocket/space to place an implant that will allow her to be larger than she is right now. Tissue expansion will allow for a larger pocket to be slowly created to allow for a larger implant and give her the bigger breasts she wants (to point, as her tissue will still dictate limits there as well).
Very few surgeons like to do direct to implant on large breasts (D+)...though there are some I have come across....and very few surgeons will do direct to implant on someone of any size who wants to be much BIGGER than they currently are because of the strain on the tissues (which can increase risk of complications such as necrosis/implant expulsion).
I notice you also later had tissue expanders?
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Dive,
I downsized quite a bit with the BMX. I was an F or maybe FF...always have had huge breasts. Around this part of the country they do direct to implant surgeries fairly often on women of all sizes. Since the implant goes under the muscle and none of us have muscles made of elastic no matter what our breast size is before surgery, it's probably a skin thing. A small breasted woman could not have enough skin left to cover the implant? I'm just guessing. I suspect it might have more to do with how much experience a PS has with direct to implant. You do have to sign a consent before surgery saying you understand that you might wake up with TE's instead - or maybe one TE and one implant - if the breast surgeon leaves thin flaps for the PS to work with, takes too much skin, or there is some other reason why the surgery plan has to be changed. My PS does not offer the option to women who've had radiation because he said the implant failure rate is 50%.
My original implants were fine, no muscle spasms, not a lot of pain. I can't take any kind of pain drug except Tylenol, and I got by fine. Unfortunately some 8&@%$ hospital worker gave me an infection which showed up on post op day one, resisted two changes of IV antibiotics, and resulted in much damage to my left side in record time. They switched me to the antibiotic of last resort, IV Vancomycin, which worked. At 14 days post op, I went back to surgery to have all the dead muscle, skin, and soft tissue removed from under my arm and onto my side. There was no longer enough good skin left to cover the implant, so the PS took it out and put in a TE on that side. I had some strong muscle spasms on the TE side even though it had no saline. Three months later, after fills, I had the exchange. The original implant on my right never was a problem but it had to be changed to a smaller implant to achieve symmetry with the beat-up side. No infection after the second and third surgeries but I was put on IV Vanc just in case.
So I have nothing but good things to say about mastectomy with immediate permanent implants. Infections happen at any stage, including after a biopsy or a cut finger. I was just unlucky. Instead of my "one and done" surgery, I'm going in next month for surgery #4 to try to repair the damage from the second surgery mainly to my muscles. If this z-plasty doesn't work, my last resort surgery will involve a Lat flap, which I really don't want.
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Hi littlecalico! Here are a couple of threads dedicated to direct-to-implant reconstruction. One appears very new with only a few posts, but the other has been around for a few years:
http://community.breastcancer.org/forum/44/topic/8...
http://community.breastcancer.org/topic_post?forum...
As I recall from one of your recent posts you will have unilateral surgery, right? I don't know how common unilateral direct-to-implant surgery is (as opposed to bilateral), but you might try posting on one of these threads in hopes of finding reassurance and the right questions to ask.
BTW - In the beginning I assumed that "MX with immediate reconstruction" meant MX with direct-to-implant reconstruction or flap surgery. But, it is also used to describe MX with immediate placement of TEs and later exchange to implants. Before that clicked I was a little confused with some of the posts I read on the reconstruction threads.
Best wishes and good luck with your research!
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So I might get my first fill today. I'm so nervous/excited that I can't sleep!!! My ps also needs to confirm that my prophylactic breast isn't infected..... Please God!!!!!
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littlecalico: I doubt that you could go larger at all with a one-step, if you are fairly small-breasted now. Perhaps your PS plans to use a Mentor Spectrum expandable as a "permanent" expander/implant? I just feel that you should get a bit more information regarding what your PS intends to do for you, so that there are NOT any surprises. Dive Cat is correct in stating that not everyone is a candidate for a one-step, which is typically always with the use of Alloderm. I would like to know more about your doctor's intentions and so should you!
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Tina, thank you for posting some links for littlecalico!
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Mommy.... I hope you don't have infections! Either way, please don't get your hopes up for fills if your incisions are draining. I never developed an infection, but I had necrosis and healing problems and the PA actually pulled fluid off to help with healing (less pressure on the tissues, vessels, etc).
Good luck at your appointment!
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Thanks TinaT,
Yes first and most importantly I want to rule out any infection. Second, fix whatever is going on so the drainage stops and the incision can heal. I worry too about the "neatness" of the incision right now. It looks a little meaty/raw:( compared to the other side. I don't know if she'll aspirated, I had to aspirated 42cc last week from this side... And then finally we will see about a fill....
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How would you know if there's necrosis???
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Mommyathome - It is my understanding that infection is caused by bacteria and presents with redness, swelling, and drainage. Necrosis is actual tissue death caused by compromised blood flow and the tissue eventually turns dark and must be removed. If an infection goes untreated or is difficult to treat it could ultimately cause necrosis, but that doesn't usually happen.
Fortunately, I never developed an infection (no redness, swelling, drainage, etc). My necrosis was the result of a rare reaction to the blue dye used for sentinel node localization in addition to the inherent circulation risks of nipple-sparing surgery. I had a long stretch of healing with tissue loss, excisions, wound packing, etc. Amazingly, it healed up pretty nicely.
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Good morning Ladies!
I just wanted to update you in my Exchange yesterday. Not even a good midwest snowstorm was stopping me from showing up for the all exciting and important E-Day
I will post photos later of day 1 in the Under construction gallery. I had mentor Medium height Siltex 275cc expanders filled to 430 cc. Much to my surprise, I was exchanged to 650cc. Mentor smooth round HP!! So, needless to say I am a tad nervous that I will resemble Pamela Anderson and not athletic, fit Mimi.
I started out a small B. I really have grown to trust and adore my PS and in pre-op I showed him two photos as a goal. I also explained that i do run and am athletic and do not want big floppy breasts to contend with. He said once in there, I had a really deep chest wall which swallowed a lot of the implant. I wanted cleavage and full and round, but not 2 cantaloupes! I will stay optimistic, he is very good. Meticulous!
So, I solemnly swear I will not post my feelings of shock, horror etc until I have let them do their thing for 2-3 months. I will post progress pictures though.
I did great pain wise. I DO hurt and feel a bit like I was stitched onto something, I had LOTS of pocket work. He explained to me that when I said I wanted symmetry for a broad shouldered girl like me, smaller implants did project but they would not give me upper pole or width as I desired. For pain- the Oxy is doing its thing and the worst part is now being restricted with arm movement etc. Exact opposite of the post MX instructions.
Finally, a HUGE thank you to all of you and especially Whippetmom for guidance, reassurance and a place to go where most of our friends at home can never, because they haven't walked down this path. You truly are amazing women!
My dear sweet daughter plays Division basketball in illinois and is a Senior, they have their annual "Pink game" on friday and it is a very special thing to be there with her, her team and to promote the message of early detection and breast density.
Hugs to all..
Mimi
Dx 10/17/2013, DCIS, 1cm, Stage 0, Grade 3, 0/2 nodes, ER-/PR-Surgery 11/07/2013 Mastectomy (Both); Lymph Node Removal (Left); Prophylactic Mastectomy (Right); Reconstruction: Tissue expander placement (Both)
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sandra....yikes, sorry to hear about your infections. Hope you find your solution soon.
I think you are misunderstanding me. I am not saying direct to implant is impossible on larger breasts, or that no one does it, but I am saying that not everyone is a good candidate and often having larger breasts does limit one in doing a true one-step...at least if they want to do NSM (see excerpt below). Those who want go go bigger than they already are are also often not proper candidates for this surgery as it is very important to allow the skin to stretch and not stress the tissues. Alloderm does help create a pocket, but the skin flap still needs to be large/healthy enough for the implant and a small-breasted woman wanting to go bigger generally does not have this yet.
I am a proponent of direct to implant too for the right candidates. I know many who have done it with success. It makes sense that you were a good candidate, even as a larger breasted woman, as you downsized. I was also, as a 32DD, given the option where I live in Canada of one-step by 2 plastic surgeons as I am doing NSM and willing to be the same size or smaller, but opted out for my own reasons and am choosing to do TEs. Littlecalico is smaller breasted and wants to upsize so has the opposite issue...she won't have tissue to remove, but needs to get a bigger pocket. Even with Alloderm, expanders are likely to be required if she wants to be bigger.
Even the doctor who pioneered direct to implant (Dr. Salzberg)...and has done hundreds if not over a thousand of them...and I know of many women through FORCE who have done NSM one-steps with him, has this to say about one-steps on larger breasts...requiring either non-NSM to remove excess tissue or a two step procedure:
Can I Have Direct to Implant Breast Reconstruction if I have Large and/or Sagging Breasts (Ptosis)?
You can have direct to implant breast reconstruction with mastectomy even with large (cup size of D - DD or larger) or ptotic breasts, which is when the nipples face downward or are positioned lower than the inframammary (bottom of breast) fold.
If you are not having nipple sparing mastectomy surgery, we can remove excess skin during the mastectomy/reconstruction surgery to create a smaller, lifted breasted and do a direct to implant procedure. If you want a nipple sparing mastectomy, we take a different approach and use a two-stage procedure. The first stage is a breast reduction and/or lift, called mastopexy. The mastopexy makes the breast shapelier and slightly smaller, fixes the ptosis and places the nipples into the correct, forward-facing position.
Six months to a year later — once the nipples have recovered and re-established an adequate blood supply to keep them viable—we perform the nipple-sparing mastectomy with direct to implant reconstruction. Dr. Salzberg has performed more of the direct to implant procedures after reduction than any surgeon in the U.S. to date.
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Galsal, Headeast, Smaarty,DiveCat, whippetmom, TinaT(sorry if I forgot someone)
Thank you so much for your answers.
Yes, I am having a unilateral reconstruction, almost two years after mastectomy + 1 year after the radiation of the breast.
The surgeon told me that he could not be specific in advance regarding the results because he said that athough my skin seemed elastic enough, one could not realize if it really was, until the skin was opened. So he said that: best case scenario, I could wake up with both an implant on the reconstructed side + another one on the heathy side to "match" the reconstructed side. With a possible further operation depending on what I/he thinks of the result (so I'm guessing size matters come here)
Or, if the skin turns out to be too "stiff" on the first operation (because of the radiation among other things), he would take it step by step:but apparently with no TE per say (I mean by that: no weekly-every other week external injection).
Also, he said that even the smallest implants he had were larger than my actual size (
talk about small breasts!); to which he added "ok, I understand and note that you want to be larger" adding that he "won't do anything that he doesn't find anatomically balanced". Which I understand. I don't want to go super large anyway. Last thing, he said that I had a minor pectorum excavatum ribcage (or "butterfly wings" ribcage in their surgeons' lexicon), it means that I have a small depression in between the breasts, which will, he said, make his task harder; basically, my natural breast tissue adapted to this and sort of "filled" the depressed area like an underlayer, before the "actual" breast protrudes. But the implant will not be able to reproduce this, or hardly.
So I'm guessing he is not very specific prior to the surgery because of all these parameters. Don't you think?
To be honest I'm not worried that he did not discuss this further. He said that I could come anytime if I needed extra information. I just want extra experience, from women like me. And also, frankly, I do not want to have extra appointments in the hospital I've been spendings days at. I've had enough :-)
I hope I can find similar cases in the forum. So Tina, I'll look up those links + exchange city post.
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littlecalico,
Have you been able to see photographs of your surgeons best, worst, and average results with this technique? Is he planning to use Alloderm?
I don't know a whole lot about implants after radiation, but I do know enough to know there is a higher complication/failure rate, so I can't say I don't have concerns about stressing the skin suddenly with a larger implant without doing expansion. Even if the skin seems "elastic" enough during surgery I believe the risk remains higher for complications after. I am just surprised he is not discussing other options at all....like TEs or possibly a flap surgery given you have had rads.
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The term immediate reconstruction is a misnomer. Multi stage reconstruction, etc is much better. Very misleading unless its explained to you about expanders.
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What is alloderm?
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Well after worrying about putting 50cc or 100cc I got none! Dr was concerned about drainage. She said there was a seroma again and undid my bottom stitches, released the fluid, cut some unhealthy skin and stitched me back up. Until next week......, seems its always something but as long as I heal and don't get infection all is good. One day at a time, right? My husband was a trooper. I've been taking pictures throughout and wouldn't u know he took the camera out and snapped pictures as she sewed me up!
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mommyathome,
That is awful! I so hope she can sew and repair with out any further complications. Alloderm is an artificial muscle basically taken from cadavers but very very safe. Many surgeons use it to support the lower part of the pocket to prevent slipping of the implant. It gets used about 50% of the time.
You will be in my thoughts fora quick resolution.
Mimi
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Hi, littlecalico--I have no TEs either. Planning to get them in a couple of months (and glad to be able to read here before I do!).
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Mimi68,
Cadavers???? Omg!!!!
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Mommyathome
It sounds worse than it is!
It is used very, very commonly. You can look it up and read about it..i felt better after I did.
Mimi
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Mommy - go ahead and 'google' Alloderm. It's not as bad as you think. In fact, I usually 'google' before I ask here so that I can refine my questions.
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Good recommendation MinusTwo...about "Googling"!!!
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Mimi68....Well, there you go! I think you will be just fine. This is why it is so hard to know until surgery, what will be needed. If more plastic surgeons WOULD accomodate and adjust for size, when there is a deep chest cavity in which to place the implants, fewer women would wake up from surgery with too small implants. I would wager that, especially after deep dissection during mastectomy, this would be the case for many women. The key is compensation and Mimi, your PS figured this out and realized that you would not have sufficient width, height or projection if he had used smaller implants.
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I usually get freaked out on google so I was looking to breast cancer.org for info
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Hi all,
Popping my head back in here to give you guys an update. We just got back from our last fill. DW liked her size (425cc), and the PS does a small overfill to accommodate the implant, so they overfilled to 460cc.
Here's the problem, the PS is planning to go with a 460cc Style 45. This size implant has an 11.4cm width, and DW's expanders are 13cm. I know this much of a width difference is a problem. What do we need to do? Is it common for the PS to close up this difference during surgery?
I know we can demand that the PS use the Style 20, but I'm not sure which style would be best. The outside edge of her TEs seem awfully wide right now, which makes me think I like the thought of a narrower implant. They look great, don't get me wrong, but they seem a little wide across the chest and are wider than her ribcage when looking at her from the front. Maybe I'm just not used to her having that sort of shape (she was flat chested before PBM). She doesn't have any chest wall deformities, but the PS said she does have wide breasts, and since she kept her nipples she can't move the breast mound much or they won't be centered. Then again, on the other hand a narrower implant would mean there is even more of a gap in the center of her chest.
I don't know what I don't know.
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RE: ALLODERM: Video depicting how Alloderm is used in single stage reconstruction, although this same method applies to two stage reconstruction with tissue expanders also. Not every PS uses Alloderm, and some insurance carriers are obstinate about approving it for reconstruction. So you need to discuss this further with your PS.
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whitenack. So why not use a 11.0 TE to begin with? It will mean significant pocket work. It is up to you and to your PS. I cannot see what SHE can see.......and like you said, "I don't know what I don't know." What would I prefer? The Style 20.
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As an addendum to the above: I would have the PS order a Style 45 and a Style 20 in the appropriate sizes [460 ccs and 475/500 ccs respectively, and try them both to see which looks best. It might well be that one will look better than the other, intraoperatively, as some of this just cannot be decided outside of the OR. I would hope she would be willing to do this, and then also enlist the aid of OR nursing staff to be advocates on your wife's behalf.
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