TE/Implant OVER pectoral Can exercise, comfortable &NO RIPPLES!
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Hey Littleblueflowers!
I've had one round of fat grafting so far - Mid June (radiation ended mid April). I just saw my plastic surgeon a week ago and he wants to check me again in another month to decide if round#2 of fat grafting is needed or proceed with tissue expanders (if I decide to reconstruct...still on the fence). He said he decides how many rounds based on response but most often does 2, sometimes 1 or 3 - every patient is different. I've seen some nice improvement after one round, skin/tissue is definitely more flexible/stretchy/soft, but not enough yet - it's not like the unradiated side. Also working with specialist PT (since I can't work on myself that well as a PT) to break up a lot of my adhesions/scar tissue. My problem is that I really don't have enough fat and I'm not willing to put on weight at age 46. He took from my hips last time, couldn't really get anything from my belly but trying at the belly resulted in a ton of scar tissue that I've thankfully been able to work through in the past 2 months to where it isn't painful anymore. If round 2 needed, he will try lateral buttocks. Not sure what he will do after recon/implants if I need a little more grafting to cover the top edge. Firni - Sorry I forgot to ask him about Denver contact. Will give myself a reminder (electronic and written) for my next apt on Sept 19th.
hugs to you all!
- xo
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Hi Andraxo, that is great. Have you thought of using Pentoxifylline 400mg three times per day and Vitamin E 400IU THREE times per day, as per several research protocols for the radiation fibrosis you have? It is a prescription, surprised your doctors haven't given it to you yet. I take it and along with the Fat Grafting, and the Hyperbaric Oxygen Therapy has returned my skin to 95%of normal. I researched the Pentoxifylline and Vitamin E myself, gave my PS copies of the studies and then he prescribed it for me. Here are some studies.:http://www.ncbi.nlm.nih.gov/pubmed/22846413
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macb04 - yes, I specifically asked about pentoxifylline after researching myself too (those same studies), but my plastic surgeon did not think it was warranted in my case. I'd also prefer not to take any prescription drugs if I can avoid them because with all drugs come side effects and I hate that. I don't even like to take vitamins, but I am taking Bcomplex, D and E right now. I made it through 6 rounds of chemo without taking anything else except for the require couple days of steroids. I have significant fibrotic changes, but true radiation fibrosis is another beast. He's mentioned HBO only if needed later. I am getting significantly better after just one round of fat grafting, I'd say 75% better in just 8 weeks. Funny that on the Tamoxifen thread many are reporting that med oncologists don't want women with ER+ tumors to take E. Thankfully my MO is fine with me taking E.
- xo
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I am in the process of reconstruction with tissue expanders under my pectoral muscles. If over the muscle is much better... and it certainly makes intuitive sense, then why did Angelina Jolie opt for under instead of over? I am wondering if it relates to her body mass index. Perhaps her decision relates to her lack of body fat.
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Over Pectoral implant reconstruction has to have something to put between the outside of the implant and the skin, like Acellular Dermal Matrix stuff, i.e. Strattice, Seri Silk Scaffolding, Alloderm or Fat Grafted Fat. Otherwise the implant edges would be easily visible. Just a guess, she didn't want the ADM stuff, or it was still only starting use in reconstruction, and PRE Pectoral has only started to happen in the past 2 years, so it was not an option for her at that time. Don't really know. It is certainly a superior option for most women. Having had it both ways, I can honestly say that it sucked big time to have my pectoral cut up and filled with a TE. Absolutely hated it.
Andraxo, can you tell me why your PS said the fibrotic changes you have are not radiation fibrosis if they are improved by the increased blood supply that occurs from Fat grafting ?
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She did have her surgery in 2013 so your time line applies. Begs the question... why did I not know this was an option. My next "fill" is on the 31st of August. I will ask my PS.
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Obviously, I have no idea which considerations governed Angelina Jolie's thought process and choice, but a few PSs were doing pre-pec implants earlier than 2013. With her resources, she would have had her pick of PSs anywhere in the world, so I doubt this option was unavailable to her. Here's a article by one of the surgeons on your list from 2015 referencing 4.6 years of follow up on the patients receiving pre-pec. (Warning: graphic photos for those who get squeamish, as well as a linkto a video of the procedure.)
http://www.beckermd.com/wp-content/uploads/2015/06/Immediate_Implant_based_Prepectoral_Breast.pdf
While ADMs are available in different thicknesses, none are sufficient to provide adequate cosmetic coverage for women with ultra-low body fat, which is the reason that I would speculate was a key factor in Angelina's decision. I have 10% body fat and was advised that I was not a suitable candidate for pre-pec recon for aesthetic reasons, as the implant edges would have been very prominent. The lower your body fat, the thinner your skin flaps. For the majority of women, pre-pec is a fabulous option and it is encouraging to see this procedure having increasing availability; hopefully widespread use will come in the next 2-3 years.
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Everyone gets some amount of fibrotic changes from radiation, true radiation fibrosis is more severe. Maybe it is semantics. The fat grafting isn't just about improving blood supply - stem cells differentiate into other cells as well. Fibrosis isn't simply about blood supply. I'm also dealing with adhesions - which are another animal. I'm a PT and see my own caseload of patients with breast cancer...this isn't new to me. The only thing new to me was cording/axillary web syndrome. I had/have it, none of my patients ever did/do - but I also work with all Navajo patients, most are overweight and cording is more common in leaner people.
Ultimately, I trust my plastic surgeon and what he recommends for me right now. I also do not want to take any drugs if I don't absolutely have to. I am improving significantly and it would be awesome to get there without pharmaceuticals. As a clinician I also know it is hard to discern what worked when you throw multiple things at something at once...especially drugs. I'd also prefer to see how much improvement I get from fat grafting alone. 8 weeks after one round is far too premature to make decisions. If at my next visit he rec medication or HBO I will do it. He listens to what I want and what suits my lifestyle. I don't even know if I want reconstruction - but my only option is over the pec implants because I'm too athletic and active (with too little body fat) for anything else.
happy Wednesday! - xo
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I am getting ever more anxious for my exchange surgery. I'll certainly update here with results or what I learn.
It's funny how I bounce around here and other sites about who is or is not a good candidate for over the muscle implants. It does seem to boil down to the aesthetic result of the whole thing. I can tell you that is absolutely NOT why I chose over the muscle.
I am at least very very lean on top. Ridiculously so, not real pretty so lean on top. You can see all my ribs, my spine, just pretty boney. You can probably reach in and grab at various internal organs, too (thanks to my also very long torso). Don't I sound just cute at this point? Oringally I was scheduled for under the muscle TEs, but I had big concerns regarding muscle spasms. My clinic actually just did a study using botox at surgery time to see if it can prevent this. I was signed up for that, but was so worried I'd get the placebo. Then, my PS showed me video of muscle animation that some have after implants under the muscle. Since you can already see everything on my chest I would be mortified to add that to my looks.
When I pressed her on which option would be best for ME, she (she does both over/under - no serious preference that I could tell) said in my case she was 50/50. She did say she had other women like me that had over implants that looked quite nice. She also said she had under women who never got over the muscle spasms and had that muscle animation. I changed my mind literally the day before my surgery. I didn't start this process with some nice cleavage or breasts I was sad to lose. Having anything on my chest with no expectations based on previous looks is making this easier from an aesthetic viewpoint.
But as downdog said, with low body fat, the edges of implants will be prominent in above the muscle implants. I very much know that now - you should see my TEs! They are simply sitting on my skin with edges showing, tabs where they are stitched to my chest wall visible. And, because my skin was very tight during the stretching process, my TEs are not filled all the way so I have folds and points sticking out in my skin. I can't really even say they are coconuts on my chest as I believe coconuts probably have a smoother shell than these mounds!
My PS will attempt fat grafting, but she doesn't think I have much to work with. She also said she will *have* to use anatomicals implants as the edges are not as prominent as on rounds. I can only imagine right now. I meet with her next Monday and surgery on 9/7. I'm ready to live with not so perfect implants. Just a little femininity but I don't want to compromise activity level or comfort (and I feel I'm at 100% for my activity level and my ROM now with these silly TEs).
I think it's easy to forget that doctors are human, too. They have their own opinions, may or may not stay up to date on new changes in their field, personality quirks... just like us. At the end of the day, they just want to go home and relax as we do. So, you might get an eager doc ready to try everything and anything, or one who is conservative and sticks with the tried and true. I would have had no clue that there were options such as over vs. under in reconstruction had the doc I randomly been assigned to hadn't mentioned it herself. In my case, I could have as easily gone to a different clinic and be sitting here with under the muscle TEs!
All I can do is share my experience which isn't quite complete yet.....There are certainly people on both sides (over and under) that are quite happy with their results.
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Thank you very much for the information and the article which I will read in depth later.
I'm not the weight I want to be at the moment having lost weight over the past few months. (5'7" 112 pounds )
Perhaps my plastic surgeon didn't think I was a candidate because of my low body fat. I dont like thinking I am missing out on a better surgery. I'm having difficulty reconciling myself to under the muscle implants but that's the road I am on.
These tiny tissue expanders make me look ridiculous. I now have many shirts with 2 pockets on the front to distract from the height of these things. But I feel cancer free... as if I could know.
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The option of prepectoral reconstruction sounds great to me. However, I don't know if I'm a candidate. I'm lean, but not extremely so. I've had a failed TE on my radiated side. It was under the pec. At the time the PS believed it was cellulitis, but I now believe it fits Red Breast Syndrome to a T. My understanding is that Red Breast Syndrome is an allergic reaction to the Alloderm or acellular dermal matrix. I understand that can now be managed without losing the TE or reconstruction. Has anyone had RBS & still had success with prepectoral Reconstruction?
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Never had to worry about being extra lean, ha, ha. I had Seri Silk Scaffolding. I wonder if that had the same problems like Red Breast Syndrome ? I haven't had any problems thank goodness. With the Seri Silk Mesh under the Grafted,wrapped around my Mentor Anatomic High Profile 495cc implant, but over my Pectoral, NO IMPLANT EDGES VISIBLE. I can't even FEEL the edges of my implant. I had Fat grafting 5 times. The Fat Grafting was with the BRAVA dome system for 4 of the procedures. I had 2 severe infections, lost an unknown quantity of Fat each infection. I think I would have been really sucessful without thoses Fat loses. Despite those loses I still got a good bit of cushion that made my OVER pectoral implant reconstruction a sucess, even after having Radiation Fibrosis. All that fat I had came in use for something after all.
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Really happy to hear you don't even feel or see your implant edges Macb04 ! That is a fantastic result! So sorry you had infection/complications. How did you like the BRAVA ? Once we knew I was going to need chemo/rads (multiple positive nodes with axially dissection) and didn't wake up from mastectomy with TEs, the BRAVA and all fat grafting (no implants) was supposed to be my plan to create breasts later. In reality though, I just don't have enough fat for BRAVA even for creating even the A/B size breasts I'd want, so we're back to implants when my soft tissue is ready.
For me, over pec implants is about being able to do all my sports and my active job (PT) - my surgeon will not do it any other way for me. In Sept if I'm told I'm ready for recon, I think I'm going to wait until next spring (assuming I decide to recon). I'm very comfortable being flat now (though with nipple sparing) and have pretty much full function/motion/strength etc. I think I'd like to enjoy snowboarding all winter without being in a post-up status or having TE fills etc. If I need another fat grafting round, I'll do that ASAP though.
Thanks everyone for sharing your stories! It always helps to hear/read more...
-xo
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Interesting conversation! The reason i went with pre pec implants was also because of my active lifestyle and job. I wanted DIEP, but was told i didnt have enough fat. However, it only takes a tiny amount of fat to graft into your chest to help heal radiation damage, and anatomical implants hopefully will look ok. So, thats the route im going. Also, my PS said the whole process should only take about 3 months, which is about all the down time i could stand! Should be all healed up by the end of January, when the skiing gets good here.
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I'm on the same path you are littleblueflowers - will be very interested to hear how you do with the upcoming TE placement and the fills, and then the over pec implants (and skiing with them!). When did you finish rads? Curious about time between ending rads, then fat grafting, and now TEs - though I know every person is different, especially in the amount of fibrotic changes from rads and recovery from that. I'm only 4 months post rads and 10 weeks post 1st fat grafting. Regardless of when my tissue is ready, I think I'd need to wait until next summer or fall for TEs and anatomical implants....part because my brain isn't on board yet with reconstruction and also because of seasonal sports (you know we have to enjoy the great snow!!). My plastic surgeon doesn't think I'll need much time to fill since I'm only looking for A or B cups at most, and my activity restrictions would only be a few weeks.
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My plastic surgeon, Dr. Reid Mueller, also does above the pec implants. My next Foob surgery will be moving the implant on top of the pec. My right arm is also severely restricted from the BMX + ALND. My pec on the right is quite a bit more developed, and hurts way more than the left, not to mention pronounced animation. I'm leaving the left alone except for fat grafting. The left turned out well, including keeping feeling, so I'm not messing with success.
I'm at the high end of normal weight (25 BMI) and he thinks there's enough tissue to hide implant edges. I'm waiting until next year for surgery. If this doesn't work, I'll do something besides another implant. They look far better than they feel
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I finished radiation last october, and started fat grafting in....um....june. Ive had two sessions of fat grafting about 6 weeks apart. My ps said my hide looked fine and ive regained a lot of skin health, so he is fine with just doing 2 sessions. I hacd to wait until my field season ends befor installing expanders. My ps says a month of fills more or less, a month of rest, then final ballistics gell implants. I am allowing 3 months because my radiated side heals about twice as slow as my prophy side. Also for weather delays and the like. I am still not totally committed to the idea either, but even the fat grafting has given me huge benifits in terms of regaining mobility reducing cording and skin health. I was crispy fried from rads. Lots of damage.
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Thank you Macb & everyone. This procedure is so encouraging to me! All of the autologous options are so frightening to me. Much as I like the idea of using my own tissue, I can't seem to face putting myself through any of them. I wish all of you the very, very best. I know there is no "one size fits all" to the difficult decisions of reconstruction, but I am so happy to hear that prepectoral recon can offer active women a better solution. I will research the Seri Silk Scaffolding and, fingers crossed, I'll find a doctor in NY to add to the list.
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I had my exchange surgery on August 23, so I'm about a week and a half out. My PS used anatomical implants. At this point I'm not super excited with how everything looks. I know I still have some swelling. I've read so much about giving it time after the exchange for things to look good. But I'm now wondering if that applies more to those doing under the muscle? I was a droopy, saggy 36DD before BMX and really was just looking forward to having perky boobs, but at this point I feel like I don't look much different than before cancer.
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I'm sorry to hear you are disappointed by how your implants look. Maybe give it more time? I hope it gets better for you. I think that Prepectoral implants are chiefly, to my mind, known for the greatly increased comfort that comes of not having your pectoral muscles cut up and disrupted. That's as compared to the traditional under pectoral implant reconstruction. If it looks realistic, that is just a bonus. Comfort is worth quite a bit to most women. I miss my saggy breast, personally, I always wish I could get it back. Perhaps that's just me.
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I think that I just had expectations of getting the nice perky boobs that everyone talks about and that didn't happen. After 18 years of saggy and droopy, I have to admit that I was looking forward to something perkier. It makes me feel extremely vain to even say that, but I was hoping for one positive thing to come out of this whole mess! I don't know if myexpectations were unrealistic with over the muscle or not. So I'm curious to know how many of us "over girls" have had their exchange and what the results were.
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Hi! I wanted to share my experience so far (still in the middle of the process, but maybe helpful for some). I was diagnosed with DCIS in mid-June and just had a single mastectomy (skin sparing and nipple sparing) on August 17th. I struggled with the reconstruction decision. Honestly, it was this decision that brought me to my knees in sobs that just tore out of me. Oh I was so sad all the way to my bones.
On one hand, I didn't want to alter healthy pec muscles or tummy muscles if doing so wouldn't cure the disease. I liked the benefits of DIEP (and I was a candidate) and I understood at the time that most reconstructions involved cutting my pectoralis. In my mind cancer was going to take one beloved part of me, why should I volunteer to let it hurt another unaffected part of me? A very significant part of me was prepared to live with my unaffected breast + no breast. I thought of it as a lopsided life, or a one-and-none life. I could do that. And I knew I would figure out how to navigate the world just fine.
On the other hand, figuring out how to navigate in a world that has expectations for our breasts seemed hard and I wasn't sure I wanted to take it on. One and none would be okay for much of the time, but not all the time. I like clothes and my figure (which has always been proportional despite weight fluctuations) in clothes. I travel all over the place with just a carry-on bag for weeks at a time which means I pack light. I couldn't imagine having to buy, let along pack, a prosthesis. What if TSA actually touched it during one of my jaunts? What if I forgot it (likely)? I would want one that was a perfect match for my brown skin tone -- which meant that it would need to change with the seasons. And since I think the uneven chest probably wouldn't have been noticeable most of the time if I opted not to wear one, I couldn't imagine what I would do with some of my favorite dresses that require two breasts.
My PS at UCSF offered me pre-pectoral and it was like the rainbows came out. I had questions about recurrence. My BS had told me that pre-pectoral would make it harder to find recurrences UNDER the implant, but in my case, there was no sign of DCIS near the chest wall so I would most likely be okay. She signed off on it.
I have no way of comparing pain levels between this surgery and one under the pectoral, but I can tell you that I'm pretty much off pain meds now. Except for at night when the TE feels like the tightest underwire bra that is maybe one size too small and has been on for one hour too long. I take a muscle relaxant so that I can sleep and by morning I'm generally fine. I remain fine except for a few tweaks resolved with Tylenol until bed time arrives.
Here's the other thing that surprised me: my PS is using plain old air to expand me. No saline. I was too scared and uncharacteristically quiet to ask about this procedure when he expanded me yesterday. So, now I'm curious about it. He did tell me that using air is lighter than saline. Never having had saline, I can't say whether this is true, but I can say that except for that underwire feeling and surgical tenderness, I don't feel any weight from the TE. I did some research about a new TE called "Airexpanders" that allow patients to expand at home, but that's not what this is. He had a big old syringe that he filled up with air in the room and then inflated my TE. 100 ccs I think. I have no idea why he didn't tell me that he would be expanding with air, and I haven't found much about air expansion online.
I'm still in the early stages of post-surgical recovery. I'm just a little over two weeks out from the surgery. I had one drain removed yesterday. The other should be removed sometime next week or the week after (given the holiday and how crazy scheduling can be). I'm still on weight restriction, can't drive, and can't lift my arm above 90 degrees. I am scared that something will go wrong, that there will be rejection or that my blood vessels won't get enough blood to the skin or that the showers I am finally allowed to take will lead to infection or maybe I should be figuring out lymphedema. I feel like so much can still go wrong with my healing, and my DCIS turned out to also contain a micro-invasion, so I need to think about additional treatment.
But despite these fears, I am so thankful for the pre-pectoral option. I can feel my chest starting to fire again as I increase movement. So far except for way more tenderness and soreness everything feels the way it used to feel when my chest fired. I'm glad that I didn't cut my chest (which has always benched and pushed and pulled for me) to re-build a breast that cancer took from me.
Here are two questions for this group. Has anyone else had their TE's (under or over the pec) expanded with air? And what questions would you suggest that I ask my PS when I next see him?
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Thanks so much for sharing ida-w! My surgeon also uses air to inflate the TEs. I haven't decided about surgery yet (see him again Sept 19th), but he was very clear that he fills them with air, not water. He also said that just before the exchange to the implants, he would switch out the air for water though. I think it was to get me used to the weight.
Hope your recovery continues to go well!
- xo
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Hi ida-w, sounds cool, to have the air expansion. I have heard of that for some below muscle reconstruction. You will have todetail theprocess as you go along for us over pectoral women.
Hi HuskerFan, I am mostly satisfied with how it turned out. It is harder to match a reconstructed breast to an unreconstructed one, which is my case. Other women here have had both done, so they may respond to your question with more info. I don't like my inframammary fold underneath my reconstructed side, doesn't quite look real, although I have great cleavage again, and thank goodness no ripples/implant edges visible.
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macb04, do you have round or anatomical implants
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I have anatomical Mentor High Profile 495cc
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macb04, I need your advice! Just had an appointment with my plastic surgeon today regarding re-attempt to insert my TE on the right side 4 months post-infection, and he wants to do this side sub-pectoral! Well, he didn't actually say that to me - I happened to overhear him tell his resident and I objected pretty strongly. What he actually said is that he will TRY to do the re-insertion pre-pectoral but he won't know until he gets in there if it will be possible, depending on the amount of damage from the infection and due to the fact that this is the breast that had radiation eight years ago. Once in there, if he can't do pre-pectoral, then he'll go sub-pectoral. Needless to say, I am NOT happy with this laissez-faire attitude he's taking on this - like it's no big deal. It IS a big deal to me, which I tried to impress on him.
Besides the IV Vitamin C, which I'm starting to research, do you have thoughts on things that can be done before this next surgery in order to increase success? There has been no mention of doing any kind of fat grafting PRIOR to surgery - only after in order to resolve cosmetic issues. Obviously I have quite a bit of research ahead of me in the next couple of days, but I thought I'd ask here as well. Thanks in advance. I'm pretty bummed and anxious right now.
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Hey Raven4mi, you are right to say whoa. Remind me again which doctor is your PS? Another question, can you go to another PS in state, or even out of state? Your PS sounds more than a bit callous about how this will effect you, if he goes under your pectoral. You need to do this in a few stages. Here is what I think will work best, because of the doctor/insurance hoops. First you likely have some degree of Radiation Fibrosis, otherwise known as Soft Tissue Radionecrosis. You have to build a case that you have this so that they have a harder time denying you the necessary Fat Grafting. You may have to appeal this, I had to. That is how I got my insurance to pay for my Fat Grafting, I went to a Wound Care Center, or you could go back to see your oncologist to get a referral for PT. Say things like "my arm/shoulder/chest feels tight, tight, all the time. "They may make you waste time, as I mentioned, with PT. That may be an unavoidable Insurance hurdle. The Wound Care Center fought for me to get Hyperbaric Oxygen Therapy. They argued for me repeatedly. I got HBOT before and immediately after each surgery /or procedure to help with healing and improve my skin integrity. I also researched Pentoxifylline and Vitamin E, which I continue to use , which has been shown to reverse Radiation fibrosis by increasing oxygenation to the affected area. It works by increasing the deformability of Red Blood Cells, so that they can fit better into tiny, damaged capillaries. There is quite a lot of research on this. Your doctors won't agree to get you the Pentoxifylline until you have a diagnosis of Radiation Fibrosis (Soft Tissue Radionecrosis ). They will say it is not indicated for you, that it has side effects. That it can possibly increase risk of bleeding, so no use within 2 weeks of surgery. I , personally, have never had any problems, but everything has some possible drawbacks, so look it up for yourself.
This is enough to get started on. Let me know if there is anything else Ican help you with.
Good luck, and don't settle for something you don't want. It is a long time to be stuck with an uncomfortable chest if you do it his way. Persevere!
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Thanks, macb04, that's an awesome synopsis. The funny thing is, I never really had ANY skin problems either during or after my radiation eight years ago, so I'm not sure it will be possible to get the radionecrosis diagnosis.
*sigh*
Thanks again for all the advice. Very valuable and a great list of things for me to research!
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Well if you had it assessed by someone experienced with Radionecrosis they could test your level of tissue "tightness". I think everyone gets some degree of it, just push them. My skin got noticeably "thicker", woodier, compared to thenormal, supple feel of the other areas of my skin. Could someone tell which skin areas had rads, versus your nonrad skin, by touch alone? Or is it exactly the same as nonrads skin?
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