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Deciding on your implant location; Subpectoral or prepectoral

Jvfireball Member Posts: 56
edited August 2021 in Breast Reconstruction

Good Afternoon Group.

I met with both my BS and PS this week and was not aware of some decisions I need to make. Specifically under or over the muscle. I was naive and thought it was just a done deal to go under the muscle/Sub-pectoral. Turns out this was not the case. Both surgeons made arguments for and against both procedures, or pros and cons if you will.

I know several people who have had under the muscle but I don't know anyone personally that has had over the muscle/pre-pectoral. Can anyone who has had that surgery comment about experience, satisfaction, implants staying in place....and anything else?

Also happy to hear from sub-pectoral patients and why they would or would not do it again.

Thank you in advance.



  • I am sub-pectoral. Didn't have a choice back when I was having my reconstruction. I would not change it. For me, the big advantage is that with the implant behind the chest muscle, the chest is pushed up to be right against the skin. This means that any skin or chest wall recurrence or new primary will be extremely easy to detect. With a smooth, firm surface, any lump growing under the skin would probably be noticeable to me when it was as small as 1mm in size. For pre-pectoral, MRI or PET screening would be used to detect recurrences. Whether this is an important factor depends on the individual of course, particularly given some of the advantages of pre-pectoral implants.

    Take a read through the following recent thread. While sub-pectoral vs. pre-pectoral wasn't the topic of this thread, the discussion did cover this issue. Read from my post of Dec. 5th 11:27 a.m. onward (mid-way down the first page).

    Topic: largest cc for direct to implant?

  • Snowflake888
    Snowflake888 Member Posts: 29

    I have sub-pectoral silicon implants. I had the surgery almost two years ago, as a pbmx, as I am BRCA2. I had my surgery done by a top plastic surgeon, at a top cancer center in Philadelphia. I never knew I had another choice, Even though I told the doctor that I lifted weights six days a week and bowled three to four days a week. I was assured I would have no problem continuing my lifestyle. After surgery, I was told not to lift or press upper body over 45 pounds. Meanwhile, I have lost so much upper body strength. This Spring, I began having pain in my shoulders and sometimes spasms. It feels like I am wearing an uncomfortable bra even when I have none on. I may someday switch my implants to pre/pec or try a diep flap. Unfortunately, I am on Coumadin, and had life threatening complications after the first surgery, so I am frightened to change. Beesie also has a point, cancer could be hard to spot under implants, but I can’t imagine living with this discomfort for too much longer. My sister has sub-pec with silicon and moderate profile and ADM following her cancer diagnosis. She has no discomfort and Is very happy with her reconstruction. My implants are high profile and over 600 ccs and no ADM was used for me. I have a constant feeling of tightness across my chest muscles. It is a difficult decision to be sure. I will be reading your answers with great interest. Good luck.

  • hopeful23
    hopeful23 Member Posts: 22

    Jvfireball, I am having unilateral mastectomy with prepectoral tissue expander placement on Dec 21. My surgeons are at Dana Farber and my plastic surgeon said he has not done a subpectoral implant in two years. I asked him if recurrence could be difficult to find with prepectoral and he said no. Since I’ve already had one recurrence, this is certainly a concern of mine, as it is for all of us. Beesie’s info has been invaluable, and I plan to continue to find out more about monitoring with a prepectoral implant. Based on people’s posts like Snowflake, I really want prepectoral to work. I have decided to proceed with prepectoral and make a final decision as I learn more. I can have the tissue expander removed, or proceed to DIEP flap in the future. It’s a tough one and I wish I knew all the answers now.

    Could you share the pros and cons from your surgeons?
    Best wishes for you.

  • veggal
    veggal Member Posts: 261

    I have had both. I would choose over the muscle any day of the week. My experience with under the muscle implants was similar to Snowflake’s. I really hated them.

  • jaybird627
    jaybird627 Member Posts: 1,227

    Question: does pre-pectoral result in the iron band/bra feeling too or just sub-pectoral? I have a new PS and a new expander over my Lat flap. The other side is 'done' and I believe sub-pectoral. I'm having that one replaced due to capsular contracture. I think on both sides I need to do sub-pectoral because of my thin and radiated skin. I have the tight band/iron bra feeling on both sides and just thought it was from the BMX?

    J ~

  • jrnj
    jrnj Member Posts: 407

    jvfireball I spent some time researching this issue. Check out the thread: TE/Implant OVER pectoral Can exercise, comfortable &NO RIPPLES! Typical of all my Drs., my PS told me nothing and put pre-pectoral expanders in, his choice. I lost them due to infection and had a lot more time to research the options. For the short time I had them, they looked and felt ok. I have thick skin. I had iron bra syndrome and a lot of pain, but I was still healing. My Drs said it would not mask a reoccurrence. I believe them that "most" reoccurences would occur in the skin/scar area and be easy to find, but I can't help but think that sub pectoral is still safer regarding finding a reoccurence. I chose to try and avoid implants and go for DIEP, which I suppose is similar to putting an implant above the muscle. and if I want a small implant after, two Drs. said it would have to be over the muscle after DIEP. One of those Dr.s would have put the initial implant under the muscle. Too many choices, too much stress. I'm scheduled for 1/7/21 for DIEP. Good luck with your decision.


  • OCDAmy
    OCDAmy Member Posts: 289

    I have a pre pec implant. My PS almost exclusively does them this way now. It’s comfortable and soft. I’ll get an MRI I believe every three years to check the integrity so I feel good knowing it will be monitored.

  • DiveCat
    DiveCat Member Posts: 290

    I have sub-pectoral. Pre-pectoral was rather uncommon when I had my PBMX. I did have tightness for a while but at some point (a long time ago) I stopped noticing any tightness. I can still kayak, swim, haul around heavy scuba tanks, lift weights, do burpees, and all that other stuff. I don’t have iron bra or any other discomfort. I did have some issues with the 410s I had just due to their firmness (not due to being sub-pectoral) but I had those exchanged about a year ago.

    I have very thin skin according to my PS and initial BS, and my BS was also good about removing as much tissue as he could which is great for risk reduction but did not help leave much cushion; I don’t think I would have been happy with results at all with pre-pectoral for me. As it is I am going for another fat grafting. I originally switched from round silicones to Allergan 410s to deal with rippling but now that I am back to smooth rounds I am going the fat grafting route - had one already and planning for next.

    For me, I have had a couple opportunities to switch and it just isn’t worth it to me given my lack of issues.

    My sister went pre-pectoral and is happy as she lifts very heavy weights, but she also has quite a bit of rippling and had to go back for an exchange to quite a bit larger plus fat grafting to try and address it.

  • mountainlover
    mountainlover Member Posts: 59

    I am only at TE stage , pre-pec , but wanted to share that my PS team told me they recommend pre-pec placement to all active women (even those, like me, who are not at all athletes , but just have an active life) as they consider it carries less risk of complications down the line.

    I was warned however that the implant would be more visible, though that would be attenuated with fat grafting, but if unhappy I could always go for sub-pec later on.

    For me comfort mattered more than very good aesthetics, so I was pleased with the recommendation.

    Now, even with the visibile TE edges and folds I can say that in terms of volume and simmetry the result is more than acceptable to me. Hopefully it won't get worse after exchange, but I'm looking forward to getting rid of the TE , again for comfort, as I understand the permanent implant should be softer.

    All the best.

  • rah2464
    rah2464 Member Posts: 1,192

    I am pre-pec as well. PS recommended because you don't animate the tissue when you engage your pectoral muscles. I don't think risk of capsular contraction or iron bra feeling is dependent on type of surgery you have, rather it is your body's response. I just recently completed a revision surgery as I had a tremendous amount of scar tissue that needed to be released. I am very thin skinned so we tried some fat grafting this time as well. I can still see edges a bit, and some rippling, but nothing is going to be absolutely perfect. My sister did sub pec, but she wasn't even offered pre-pec and this was a year ago. She is very happy as well with her surgical direction. I guess I am not much help here. Perhaps the takeaway is that both surgeries are being performed frequently now so go with whatever choice feels right to you.

  • summerangel
    summerangel Member Posts: 182

    Snowflake, I think the caution against lifting more than 45 pounds was probably for the healing period. I regularly lift more than that without issues.

    I have sub-pec implants, as pre-pec was quite rare when I had my surgery. I am active and lift weights. Like DiveCat, I had a surgeon who was very good at removing all breast tissue and I have pretty thin skin. I had the iron bra issue and pretty severe pain during my time with TEs, but those issues went away with the implants and exercise. I think regular exercise and stretching helped a lot with making them comfortable. All of this being said, I would most likely choose sub-pec again. It's difficult to say for sure because if my surgeon had said that active women have trouble with sub-pec it probably would have made me choose pre-pec. I'm very happy with my implants, though, as they look great and feel good. The only thing I've had to change is in my exercise routine - I no longer do push ups because the implants move too far to my armpits when I do them.

  • SuQu31
    SuQu31 Member Posts: 73

    I had sub pectoral with lat flaps and implants. That is what my surgeon suggested for me, so I went with it. It turned out that I needed additional skin removed because of a close margin, so the extra skin afforded by the flap ended up being helpful in the healing process. I am very pleased cosmetically with my outcome. I'm also comforted by the knowledge that a recurrence would be more quickly noticeable to me, particularly because of the close margin (hopefully addressed completely by the surgery), as well as the fact that I am an incredible worrier.

    I occasionally have some tightness/iron bra feeling, but it is typically eased by stretching. I'm not particularly strong in my upper body anyway, but I have noticed some loss of strength, although it gets better all the time. If I had actually worked to regain the strength, I'm sure that would have speeded up the process!

    Just wanted to share my experience. Best wishes as you move through this process- these are hard choices

  • Jvfireball
    Jvfireball Member Posts: 56


    Thank you for your response and the feed you led me to look at. I appreciate your concerns regarding monitoring. There is so much to process and learn. I don't even know what to ask about yet, but I learning at lightning speed.

    Thank you again, I am taking this all in.


  • Jvfireball
    Jvfireball Member Posts: 56


    Thank you for sharing your journey with me. Sounds like you have had a few curve balls in addition thrown your way. I appreciate hearing your story and add your experineces and concerns to my bag of knowledge to aid in my decisions.

    Wish you continued recovery in what you choose if anything going forward.

    Thank you


  • Jvfireball
    Jvfireball Member Posts: 56


    Praying for the 21st. Thank you for letting me know what you choose. It all helps in this daunting process.

    Thank you Julie

  • Jvfireball
    Jvfireball Member Posts: 56


    Thank you very much. I appreciate hearing that more than you know., Well probably not more because you have already walked this path!

    Thank you


  • Jvfireball
    Jvfireball Member Posts: 56


    Thank you Judy I appreciate hearing your story and why you choose what you choose and what your Drs choose too. This is so much but hearing good stories for both is very comforting.

    Thank you


  • Jvfireball
    Jvfireball Member Posts: 56


    Thank you so much for that. I used to be in the military and very athletic. I will never be that active again but I do live an active life so I love hearing what your medical staff told and advised you. Thank you!!


  • Jvfireball
    Jvfireball Member Posts: 56

    Thank you everyone.

    All this info is awesome. I really appreciate it. I feel a lot less blind about pre-pec. I know a lot of sub-pec but had no reference points for pre.

    Thank you!!!


  • Sherry2019
    Sherry2019 Member Posts: 7

    Hello ladies

    Anyone with more than 1 year with tissue expander? I had my tissue expander last July 2020 and after that I had my radiation from early October till end October 2020 yesterday December 10 2020 my plastic surgeon told me to wait to heal first , and I asked him when to have my implants he said I m going have an appointment with him on March 2021 from there he said will plan for my permanent implants I also currently under target this tissue expander is so uncomfortable 😓 anyone same as me that's have longer time with tissue expander?

  • mountainlover
    mountainlover Member Posts: 59

    well, I was supposed to have fat grafting first in Oct/Nov 2021 then after a few months the exchange but now due to Covid all non elective surgeries are blocked. It might well be a year before I have the exchange unfortunately.

  • NancyGC
    NancyGC Member Posts: 6

    Anyone have TE sub pec, and then go DIEP pre-pec?

  • minustwo
    minustwo Member Posts: 13,000

    Sherry - here's the link to the "exchange" thread. If I remember a number of people had long term TEs. Lots of good questions & information here by people making their own decisions.

  • jaybird627
    jaybird627 Member Posts: 1,227

    NancyGC - that is a good questrion! I have NO idea what my current is nor what my previous were.

  • Crojas1221
    Crojas1221 Member Posts: 5

    @Sherry2019, ugh. Expanders. Mine weren't in for a full year, but it was about six uncomfortable months. That said, I finally finished all reconstruction surgeries in March of this year and nine months's all been worth it. I hope you get them out soon. You'll be so much more comfortable! Have a restful holiday and new yer!

  • mountainmomma57
    mountainmomma57 Member Posts: 1

    Well, oddly enough I have one of each. There was a failure to heal on left side and they had to go back in and put that one under so as to have more blood flow under the skin graft, the other they left over pectoral. I do not notice any difference, they look balanced and feel the same. They may have done more fat grafting on that side but all is well,,,,,, for now!

  • ammie
    ammie Member Posts: 7

    MountainMom, thank you for sharing this, it's encouraging to learn that you have both placements and are equally happy with both.

    This has been my dilemma... I already have sub-pec breast implants (have had them for 15 years), and have had no issues with them other than the initial tightness and adjustment period.

    I've visited 4 plastic surgeons and they are 50-50 split on recommending pre-pec vs sub-pec. I was most concerned about ability to detect new occurrences, and also how well do the pre-pec implants fare over the long haul?

    When PS's do regular breast augmentations, the majority of them still use sub-pec placement. The reason is that with regular breast augmentations, the pre-pec placement doesn't do so well over the long term (more risk of capsular contracture, ripples, bottoming out).

    Yet the same PS's who prefer sub-pec for breast augmentation, also now prefer pre-pec for reconstruction. Very confusing.

    I haven't had my unilateral mastectomy or reconstruction done yet, but there is a possibility that I'll have one pre-pec or dual-plane after that, while my “healthy" augmented breast will remain sub-pec.

  • BunnyADS
    BunnyADS Member Posts: 1

    I had pre pec done one year ago. (Unfortunately the radiated breast got infected, so the implant was removed, and I am waiting for reconstruction on that side - but this had nothing to do with the placement of the implant.) I can speak about the implant that is still in. It is amazing, gorgeous, no pain, no mobility issues, no iron bra. Just a rubber ball under your skin - which is weird for sure - but looks so good and causes no hinderance at all. My understanding is that many plastic surgeons, often older ones, were never trained in this procedure as it is relatively "new" (not really) and so they encourage sub pec which is how they were trained and what they have been performing for years. I can't say enough, in my case, how gorgeous, unrestrictive, and easy peasy pre pec has been.

  • meadow99
    meadow99 Member Posts: 3

    Hi Mountain lover,

    Thank you for your post. Currently, I have perpectoral TE. My PS does prepectoral only. Got a consult who said the best cosmetic outcome is subpectoral. Have you had your exchange, yet? If yes, how would you rate your cosmetic result? I am thin and have thin skin. I will have fat grafting. I just want to be able to wear a low cut top without the upper pole of my breasts looking like a shelf. Looking forward to hearing from you. Best.

  • meadow99
    meadow99 Member Posts: 3

    Hi Mountain lover,

    Thank you for your post. Currently, I have perpectoral TE. My PS does prepectoral only. Got a consult who said the best cosmetic outcome is subpectoral. Have you had your exchange, yet? If yes, how would you rate your cosmetic result? I am thin and have thin skin. I will have fat grafting. I just want to be able to wear a low cut top without the upper pole of my breasts looking like a shelf. Looking forward to hearing from you. Best.