TE/Implant OVER pectoral Can exercise, comfortable &NO RIPPLES!
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Saw this abstract and thought people on this thread might be interested...
Ann Surg Oncol. 2018 Jul 5. doi: 10.1245/s10434-018-6602-7. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/29978367
"Impact of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction."
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Hi brcatutu,
Read this posting from ReadyAbout from May 21st, then May 23rd and then the one below, (forgot the date) after she got HBOT for her almost Necrotic Nipples. Ignore your PS and BS, ReadyAbout 's doctor told her nothing could be done and to pray it worked out. They haven't read the research if they have any objections to HBOT. You have to think outside the box. Remember, in the end, it's your body, not theirs.
Find a Wound Care Center ASAP. I hate to say it, but it might be your only hope. Also hugely push the Vitamin C. Remember you CAN NOT overdose on Vitamin C if you have normal kidney and bowel function. At times after surgery I was taking 6 to 8 grams of Vitamin C per day. When you have more Vitamin C than your body needs you get some loose stools, that's the worst that happens. Vitamin C is CRUCIAL for Collagen formation,. for strong wound healing.
Best of Luck to you. I hope you get to a Wound Care Center ASAP and start HBOT really soon.
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macb04: you are my favorite person whom I've never met! I did 5 treatments of hyperbaric oxygen last week and my left side looks SO GOOD! I do have one area on the nipple where dead skin came off, leaving an open wound, but that will heal and overall I'm just amazed at how quickly the tissue has responded. Since I am getting this done at a wound care clinic, I have to be "discharged" from treatment by the attending doctor but I hope that will happen on Thursday. Also, my 19 year old volunteered to drive me to the clinic every morning at 7:30 a.m. and I think it makes her feel good to play a role in my recovery. I've had one setback: overwhelming nerve pain in chest/armpit/sides - it's so bad that I have to take Percocet twice a day or I'm in tears. The PS surgeon thinks that will resolve in a week. I have to wait on my first fill since my tissue wasn't ready when I saw the PS, but in the meantime, I'm doing leprechaun kicks about how my tissue is doing. I've also done the liposomal Vitamin C every day, per your advice. Thank you, macb04
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Hi Besa,
Thanks for the study. I will copy the link to the start of the Thread, as it is really good info that people might want to reference.
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thank you everyone!! sounds like 7 weeks out I should be good to go. Brcatutu, definitely keep your eye on the nipple and call the office if you need to. Aquaphor is great to keep it moist should the darkness be from the area sloughing a bit which I hope is the case. Hopefully not a blood flow issue. I had nitro paste put on right after surgery and kept it on 3 days. I hope that improves things for you. Keep us posted
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brcatutu, sorry to hear of this development!! I don't have any advice as I lost my nips at mx. You may want to start a topic on the subject. I hope you get some answers and sending up healing prayers for you!!
macb04, I have a feeling all the Hopkins docs do pre-pec. I didn't come out and ask Parker-Broderick, but during my consult for revision, we talked about swapping out my pre-pecs for smaller ones and she didn't say anything about preferring under the muscle. I am waiting to hear back from her after she chats with my old PS about my case as to the next steps. I will let you know once I am certain.
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I’m meeting with Parker Broderick, Chang and Singh over the next several weeks. I’ll let you know what I find out. I really appreciate the understanding I find n this site.
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I just wanted to let you all know how helpful this entire post was in making my decision to move forward with prophylactic bilateral mastectomy. It's been two weeks since my surgery - nipple sparing, pre-pectoral, direct to implant - and although I'm sore and still nervous something could go wrong, I'm absolutely thrilled with my results so far! Funny enough, at my follow up appt with my breast surgeon, she even made the comment that they "look incredible".
My PS is Dr. Nahabedian in McLean,VA - same practice as Dr. Venturi. Their practice is strictly pre-pectoral, unless there are extenuating circumstances. Because this was prophylactic, and because I never seem to do things in the normal manner, I met with the PS before I had decided on what BS to use. Dr. N gave me a recommendation, and said that it's just as important to factor the technique and skills of the BS as it is of the PS. I'm probably not wording that well, my brain is still a little foggy.
I'm still swollen and sore, but that's to be expected (again, only two weeks out from surgery). Dr. N did mention that I might want to do some fat grafting later on, but it was too soon to tell if I'd want/need it.
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Welcome Inigo. I added your PS to the list. Hope you continue to heal well and stay happy with your results
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Hi All,
After long thought I have removed my former PS Dr Bryan McIntosh from the list. I had thought about doing that for a while because he made a completely illogical move during the TE/Implant Exchange in putting in a 425cc implant when the TE had been inflated to 600cc ( Which was only a small bit different to my R real breast)
He used some spastic computer photo program to make that decision without telling me he was going to go that small. That was my 14th reconstruction surgery. When I woke up I IMMEDIATELY KNEW IT WAS A MISTAKE, AND WAY, WAY TOO SMALL. I was Lopsided.
So I right away had to plan another surgery, a 15th Reconstruction surgery, and I had just woken up in pain from the 14th Reconstruction surgery. A few days later I went to see him for the Post-Op visit and he agreed the 425cc implant was too small, and not a match to my R breast. He then blamed the computer program he used for causing the error.
So about 3 months after the 14th Reconstruction surgery, I had a 15th Reconstruction surgery. As he had chopped away the loose skin that I went to months of effort to grow with weekly fills of the TE, to put in the too small 425cc implant, for the 15th surgery he didn't have enough loose skin to fit any larger implant than the 495cc.
Remember, the TE had been almost a match at 600cc, and the best I could have was a 495cc. It is still too small. Also I had to pay another couple thousand dollars out of pocket for a 15th surgery I should not have had to. I look ok in a padded bras, and add a little one of those silicone breast lift pieces to make it look more symmetrical. After 15 surgeries I should be able to look symmetrical when nude, and I don't. I try to never look. It looks like I have the breasts of 2 different women.
I could have a 16TH surgery on my R breast, 16th!!!!!!!!!!!!!!!!!!!, but I don't F*cking Want To!!!!!!!! McIntosh never even apologized for the complete screw up. So I will live with my somewhat lopsided shape, annd hope it doesn't get worse, just part of my suffering, being at the mercy of the bc industry.
Phweew, sorry all for the rant, but I had to get that off my mutilated, ( I mean reconstructed) chest. I can usually bury the grief, but not all the time. Sometimes it just comes boiling out, like if I actually look at myself in the nude. So McIntosh is off the list........
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brcatutu- my nipples and areolas turns very dark purple/black and then pinked back up a few days later. They did scab for about 3-4 weeks though, I was instructed to keep bacitracin on them all the time. I had tissue expanders placed at the time of surgery and they were left empty so extra stress was not put on my nipples. I have heard wonderful things about hyperbaric chambers, just because your dr doesn’t bring like them doesn’t mean you can’t take try them. What’s the worst that could happen? Nipples dont make it? I hope you’re just juat dealing with some bruising and everything aurvives
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I have pre pectoral TEs in and will have an exchange after I'm done with chemo - so mid September probably. I'm getting a second opinion from another PS next month. I'm not entirely confident with my PS. I have a 34 inch chest and he put the widest largest expanders in. 16 cm wide and 700ccs! even though I told him I eventually wanted to be a small C cup. I've been expanded to 550 and they are low and wide and square looking. I'm doing no more fills. I know the expanders are weird looking but this is too weird. Also my right expander has slid sideways. I'm wrapping my chest with an ace bandage to hold my right breast in place. I have zero regrets about having a double mastectomy. Everything is painless and comfortable from the surgery at this point. I want to talk to another PS about implant selection and pocket revision. We go into all of this so quickly with so little information and to some extent have to trust they know what they are doing. I wish I had know the tissue expanders came in so many shapes and sizes.
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macb04 - Please don't apologize for the rant. I'm so sorry that your surgical history is so long and unsatisfying! I would have been furious. There is enough to grieve with the loss of a part of your body without having to be reminded of what's still not right.
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Thanks NotVeryBrave. I do have boiling, Volcanic Rage, just simmering below the surface, which occasionally errupts. I suppose it would be less terrible if I had ever been told NED or I was cured or anything, but the stinking bc industry doctors wreaked me, left me for dead,so to speak. A veritable Hit and Run driver experience. I would guess they expected me to be dead by now, hinted that was what they expected, so I don't understand why this mx mutilation was supposed to be worth doing.
I am NOT grateful. I will NEVER be grateful for the awful mess that has been made of my body.
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MacB, your surgeon is very lucky not to be MY surgeon. He would be reported to the state at best and probably sued as well. He has eyes! Any five year old would have been able to see the size discrepancy during surgery. It sounds as though he just stuck the implant in and closed you up without carefully checking for symmetry! Anyway, you let him off easy and I sure hope his techniques have improved.
Sorry this all happened.
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Thank VegGal. I saw your post before you deleted it. I am still irate, because to achieve symmetry I would have to go through all the hardship of another surgery, all the expense, and time lost from work. Not to mention the RISKs of an 16th surgery. If I thought I could sucessfully sue for damages, I would do it.
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Macb04 I am so sorry for the heartache you are experiencing. I understand not looking in a mirror. I am asymetrical after my lumpectomy. I look fine in clothing now that I found a bra that makes me look even; however I never look at myself in the mirror while nude. That is quite a feet while in a hotel bathroom and the shower is across from the mirror. Your PS either put the wrong numbers into the computer app or did not properly learn how to use it. I think you do have a legal case. The hospital should cover the cost for your next surgery should you decide to try again in the future.
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My PS talks to my husband not me, doesn't explain what he will do, responds to questions with irritation. I get the feeling he is like a tenured teacher that's just waiting to retire. I actually think he is quite capable and has a reputation in the area of being good. But I don't think he cares any more. He does not instill confidence. What happens to us is barbaric really. I'm getting a second opinion in about 10 days. The silver lining of this chemo is we have the time to maybe be more in control of this next step in the PS journey. Macbo4 breast cancer is hard enough without having to go through what you have. I'm so sorry. It just makes me so angry.
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MacB, at the very least you can appropriately review your surgeon online. Also, maybe run the case by an attorney. Most will offer a free consultation. In my opinion, a refund from the surgeon or a payment for a revision would be fair compensation and doesn't get into the gray area of "pain and suffering," etc.
Anyone who is unhappy with the surgeon's demeanor prior to surgery should seriously consider finding another. It usually does not get better and this will be a semi-long term relationship. It's important to feel positive about every member of your care team!
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Thats again VegGal, and Rachecarter35 and JoniB. I think I will talk to a lawyer. Probably nothing will come of it, but at least I will feel that I tried to get some kind of fair treatment.
At the time McIntosh was first my PS I had actually thought he was a nice enough person. He didn't like that I was outspoken. Once I overheard him talking about me to someone in the hall saying something about I wasn't rude, but I said things that way because I was from NY. After he realized he had put in a too small implant (425cc), he could have owned up to his mistake and apologized, at a minimum, and offer to cut me a deal, or a huge discount on the resurgery exchange I had to do because he messed up. He knew, ( because I mentioned it more than once) that I had been impoverished by the whole bc/reconstruction nightmare. My husband was out of work, on disability at the time because of a tib/fib fracture from his work. He knew it was a financial hardship to have to do another x-change sugery.
Since I didn't want to go hunting around for another new PS, I didn't get into a fight with him about having to pay him, again, for the surgery 3 months after the first implant exchange, (15th surgery). He knew I had already had my R breast lifted, and that I was supposed to be done with reconstruction . The last implant surgery he did put in a 495cc implant, but really needed a 550cc or slightly bigger. There wasn't enough room in my skin envelope because he cut away the skin, the first x-change, to fit the much too small 425cc implant. I would have to have another TE to stretch the skin out, AGAIN , to make room if I wanted to get a bigger implant. Or I could potentially have at Fat Grafting, but I barely got through with things as it was, because of the severe radiation fibrosis damage made most of my grafted fat die off and be reabsorbed. I have had so many terrible problems due to medical incompetence. I remember almost an entire year with a huge crater on my chest following a large infection from fat grafting.
I want symmetry, but don't want another surgery. I am afraid, with my history, that either they would finally suceed in killing me off, or that I would get another severe infection. So I read about this expensive Laser Breast Lift by this device called Thermibreast. I don't know if it would work much, or at all. I have read it can give a bit of a lift, which would bring me closer to symmetry. Dr Lisa Cassileth, the LA Plastic Surgeon, up on the list above, does it in her practice. I am not ready to do anything at the moment, but I want to know about all my options.
Anyone have a recommendation of a good lawyer who might be helpful to speak about my situation? If you have any suggestions you can PM me.
Thanks again to you all. It helps to know other women understand thef*cked up mess my PS and other medical professionals have made of my life.
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Hey Rachecarter35, I didn't say this earlier but you deserve a PS with the decency to speak directly to you. You deserve the courtesy and kindness, you are the one who has been through the ringer. If this PS is starting out this rude ( and ask anyone else, this is pure rudeness to ignore you this way), then it will never get any better. He will never take your opinions into account. Tell him to take a hike!
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Thank you macbo3. He did my first surgery and although the expanders are way too large the rest of his work was good. Although I had misgivings about him it made sense to stay with him during the mastectomy stage because he was part of the team that was treating me for cancer. But now it's about aesthetics too and yes I need to be heard. I am going to a highly reputable PS in San Francisco for a second opinion on August 2 and am hoping my insurance will cover him doing the exchange if I like him. He is out of my area so we will see.
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Mac, I am very sorry for all you have been through. No need to bury your grief here. I can't imagine going through what you have. Take your time looking at your options before #16. I'm sorry I have no advice but only support. Rachel, i hope your second opinion is better and if not, find a 3rd. Don't go back to #1, listen to your gut. In my opinion you shouldn't have to be the one to know TEs come in different sizes, the PS are the experts. You should not have to wrap an ace around your chest, good grief!. Maybe TEs are supposed to look" weird". My PS at time of mastectomy kept warning me that I may too but reassured me that it's not the finished product. It's been the total opposite. If these foobs weren't so hard I would keep them they look that good. It can be done taking into account our own pre existing conditions. Don't settle for less and remember we have time on our side for this phase. I was originally scheduled 6 weeks out ..which is the very earliest he will exchange...from last chemo with no issues at all. PS asked if we could bump it back a few weeks just to give best chances of chemo being out of my body so exchange will be at 9 weeks. Keep us posted on the 2nd opinion!
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I guess I'm naive or something. I thought that reconstruction was covered by insurance - under law? I've only had the one surgery, but I was only financially responsible for the copays to the doctors and the hospital.
I will be having another surgery next month to remove an area under the L nipple that has been growing and changing for almost a year. I'm trying to have my PS be a part of the operation so that he can fix the implant that rotated on the R side. I do worry about complications, but the concerning area needs to go. I just hope that fixing the rotation doesn't mess up something else!
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macb04, my heart goes out to you!! I had no idea of all you have gone through. I can't imagine going through 15 surgeries, I am upset at having to have my 5th! My new ps, Kristen Parker Broderick is actually hesitant to do it because she is concerned over tissue healing since I have already been opened up 4 times. I have come across Dr Cassileth's website in my research. She has a lot of good info on her site. I hope and pray you can get to a place of satisfaction and peace after all you have been through!! I do know that if a dr is out of network you can ask for an exception with insurance company to pay out of network if there is not an in network surgeon that does the procedure you want. I found that out when looking into the Center for Restorative Breast Surgery in New Orleans. I just don't want to travel that far. Cyber hugs to you!!
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Hi all. I wanted to update to let you know I met with Dr Singh in MD yesterday. I really liked him. He’s very personable and straight forward. I’m seeing Parker-Broderick and Chang soon and Dr Singh suggested I also see Dr Sheri Slezak at Univ of MD and Michelle Manahan at JHH. He said they’re both very talented as well. I like that he seemed to genuinely want the best possible outcome for me rather than simply to make money. I’ll do a few more consults, then make a decision. I’m so grateful for this board and all of you. I’m sorry for those that are having problems. As if we haven’t been through enough already..
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Dr. Singh is doing my pre-pec implant reconstruction and I've been very happy with both him and his staff. I agree that he's more concerned with the outcome than just getting the work. Most of my visits have been with his PA (she does the fills) and she's awesome. I had TEs placed in June; they look pretty good and the scars are very thin. I'll probably have my exchange in August or September. Good luck with your decision!
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Hi, I'm new here but have been following this thread for days and am facing a with a decision of how to do the reconstruction and I'm still very overwhelmed/scared. I'm only 39, DCIS both breasts (left side dx age 37, had a lumpectomy and turned down rads, right side dx 2 months ago). I'm thin, 5'6", 120 lbs, and fairly active (tennis, pilates, walking, etc) but not sporty. Currently 34B and want to stay my size or maybe a bit bigger (a C).
Part of the stress is that noone is agreeing with each other on the pros/cons of each method my end. Most challenging is that my current BS who I trust and is very highly regarded did my lumpectomy beautifully two years ago doesn't like prepectoral because he thinks the results look better under the muscle plus thinks the risk of complications or losing the nipple is higher with the latter, even though the PS who would do the prepectoral was one of the two he referred me to in the first place (!!).. but when I told him she wanted to do over the muscle he said "Oh, I don't like it when she does that"...and I died. He also has concerns about fat grafting due to calcifications. Separately, he also doesn't think all in one surgeries make sense due to the added stress on the nipple when healing, he wants things to have a chance to heal before putting any weight in there. So- he likes under the muscle with TE (2 steps). That said, he'll support whatever I decide.
Here are my 3 options:
—BS #1 at Cedars (my current BS mentioned above) + PS #1 who does prepectoral with AlloDerm, TE, plus fat grafting in the 2nd surgery. PS said we actually have 10 years worth of data, the risk of complications is NOT higher, and said she passionately said she would not personally get under the muscle or let a family member or friend of hers do so, says it actually reduces the risk of capsular contraction, etc. Said she'd never had anyone switch back to under the muscle and 90% of her surgeries these days are over the muscle.
—BS #1 + PS #2 who does under the muscle with TE in 1 or 2 stages but prefers 2 stages. I liked him a lot and he's highly regarded. He felt the layer of muscle over the implant at the top really gives a better aesthetic result and says he reduces the amount of muscle animation by releasing the bottom of the muscle (doesn't everyone does that? not sure if that's a point of distinction) and he uses mesh (Vicryl) not AlloDerm. I should mentioned that if I were just making the decision based on our meeting, I think I would go with him. We had a followup consult after BS #1 scared me about pre-pectoral and an open and frank conversation about the younger generation strongly moving this method and that it's a huge push from the industry right now. He's heard about and seen some good results, he's just been at this a long long time and seen things come and go that everyone was excited about. And he has personally corrected a few complications from PS #1 but did not disparage her in anyway and said people have been saying she has been getting some nice results.
—BS #2 + PS #2 (City of Hope Team) who think under the muscle (dual plane) no TE is the way to go aesthetically (and swap out for a larger implant later if you want 4-6 months later). Uses AlloDerm at bottom. Says risk NOT greater than 2 steps (as BS #1 feels) as you use something similar weight or slightly under to your current breast tissue. I really liked the female BS #2 and she is head of the program there and a doctor I love and trust referred me to her. PS #2 feels direct to implant under the muscle best for final nipple placement as TE can result in them off to the side a bit, and didn't see the purpose in TE as I could use an implant my current size and 4-6 months later once healed swap out for larger if I wanted so why commit yourself in advance to another surgery? The PS said re: prepectoral idea that he had personally corrected several gone awry elsewhere, showed me pics of rippling, didn't think I really had as much fat as I thought I would for grafting as only 25% extracted is usable and that it could be deforming of where they take it out, etc. I told him my concern about muscle animation and he felt there's no surgical way to reduce that. Hmm. He also is the only one who likes to use softer implants vs the harder cohesives and swap only if there's rippling because it gives you a much softer result in terms of hugs etc. but I get to decide of course.
There's a 4th PS I saw who is also been at this a long time and was referred by BS#1 for a third opinion, also told me not to do over the muscle OR fat graphing because of calcifications that you may need to biopsy later to tell if they are scar or cancer and he quoted a crazy high complication rate like 20% for prepectoral.
I can honestly say the people I'm seeing are amongst the best in Los Angeles. They are ALL the chiefs or heads of their respective programs. I'm lucky this way. But I've read so many posts, and so many abstracts, and honestly feel frozen. It would be so much easier for me if BS#1 agreed with PS #1 about prepectoral (but at least he likes her a lot as a PS and said he would support me giving it a try). All PS' noted how important the work of the BS is to what they do so having a team that works together well feels v. important. Both PS #2 & #3 made a point to mention how important the work of the BS was. PS #2 also mentioned that BS#1 is typically very aggressive, ie. thinner flaps (which worries me for PS #1) but he can ease up a bit when it's not invasive and they'd been working together a long time.
I know I'm asking this on the prepectoral forum, but, any words of wisdom for making this decision would be appreciated especially if you've had it done one way. I'm crying more do to the stress of making the right reconstruction decision than I am from the thought of a mastectomy. Thank you!
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Well - it seems that you've certainly done your homework! That's a lot of opinions and preferences. A lot to sift through. It sounds like maybe BS #1 and PS #1 ring true to you. If so - maybe that's your answer.
I had all of chemo to make a decision about surgery - and then ended up choosing BMX and feeling very rushed. I had 2 BS consults and only saw 1 PS. I went with him because I had faith in the BS that recommended him. I wanted only one surgery if at all possible.
Problems? Anatomical implants and one has turned - mostly just noticeable to me. Rippling - seemed more obvious early on and not so much now. Infection - at 5 weeks after surgery and required 3 days in the hospital.
I can also say that I have a lump under the areola on the cancer side. Repeat imaging over almost a year has not shown anything concerning, but ... I'm having it removed next month. I'm tired of watching it and worrying. I'm hoping to have the implant (other side, of course!) rotated back at the same time. But that requires scheduling both doctors again.
My BS is against fat grafting, at least within the first few years. She worries about various lumps and bumps that have to be assessed. So I don't know if I'll ever have that done. I thought about it a lot earlier in this process - not so much now.
It's a lot to process and many times I wished that someone would just tell me what to do! Good luck with everything.
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Hi aisling,
It is always a complicated process to figure our what you want to do. I started this thread because I wanted to make it easy for women to know about the Prepectoral Implant Reconstruction method versus the Subpectoral one. I didn't have the results I wanted exactly, see my recent posts, but that was due to my PS making a bad judgment call for implant sizing, not from a fault of the over Pectoral technique.
I think that good aesthetic results are very achievable by Prepectoral. There is no animation defect with Prepectoral Implant Reconstruction, whereas scores of women are complaining about animation defect, looks quite freakish in my opinion.
Also scores of women are just physically uncomfortable having their pectoral muscle cut and stuffed like a Cornish Game Hen. I speak from experience. I hated, completely detested, the feeling of having a TE under my poor tortured Pectoral Muscle. My strength was gone. No one mentioned that would be affected. I couldn't open a bag of chips. Until your pectoral muscle is disrupted, you have no idea how much you have been using your Pectoral Muscles to just do ordinary things. If you are a fit person like me, the loss of strength was really awful.
The tightness was pretty bad having the Subpectoral TE, way, way worse than having a Prepectoral TE. I did both. See my long, convoluted Reconstruction story for details, but basically I speak from personal experience of both methods. The perpetual tightness of something stuffed under my Pectoral Muscle was just unending misery for me. I know that is not the case for everyone, but it was bad for me and lots of other women as well, who have discussed it on the BCO boards.
I know that fat grafting can cause calcifications, some of the time. Some people get very worried about this and other facets of the whole bc mess. That is a very individual variable, that I can not address. I just know that I don't waste any time thinking about it, too many other fish to fry, if you know what I mean.
Good luck. You are thinking this through beforehand, and being very thorough, so I think you will be happier with rhe results in the long term, no matter what you choose.
Macb04
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My biggest concern when making my surgery decisions was wanting to avoid chronic pain. My mother had gone into surgeries early in her life that left her in pain all the rest of her life. I chose to go prepectoral mostly for this reason. I'm eight weeks out and don't know what the final out come will be once I have my TE/implant exchange. But at this point I like the way things look and I'm completely pain free with full range of motion. I'm not entirely happy with my PS. He put in way too large TEs and I'm going to have to have some pocket revision at the exchange. I'm getting a second opinion this next week regarding implant selection. So many decisions. Good luck.
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