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Direct to implant, plastic surgeons only want to do prepectoral

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coffeluver
coffeluver Member Posts: 9
edited April 2023 in Breast Reconstruction

Met with 2 plastic surgeons in my area and both said 'under the muscle' implants for reconstruction are a thing of the past and modern doctors only do prepectoral implants now with ADMs (allograft to create the pocket). The reason being that under the muscle implants can cause animation deformity when flexing the muscle. But one of these surgeons was either more honest, or trying to promote his flap surgeries, because he admitted that my skin envelope might not be thick enough to hide the implant! I'm 5'7 and 120 lb, so low BMI. He also said fat transfer doesn't really work well after mastectomy because there is no native tissue left for the fat to 'stick'. But still, no mention of trying the old-fashioned subglandular implants. The pectoralis muscle will conceal at least part of the implant if inserted under the muscle. Now my surgery is booked and I'm in the awkward position of questioning whether the prepectoral implant is the best plan. Also should add that I'm not at all athletic and have probably never even intentionally flexed this pectoral muscle in my life! Has anyone out there gotten prepectoral implants which actually look good? If you had fat transfer afterward, did it work?

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  • coffeluver
    coffeluver Member Posts: 9
    edited April 2023
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    OP, here. I just postponed my mastectomy surgery because I didn't feel confident about the cosmetic result with the prepectoral implants. I had the ALH & radial scars excised instead to buy more time to plan for a good cosmetic outcome. I also had my breast surgeon measure the amount of my subcutaneous fat on the ultrasound. He said it measured 8.3 mm, which he said is average. For obese women, it can go up to 15 mm and a thin skin envelope is 3 mm. Still, I'm not convinced prepectoral is the way to go. I really want to avoid the step-off deformity at the upper pole because I feel the most important thing is to not have visible breast implants in clothes and bikinis. I have a consultation with a plastic surgeon who is willing to do dual plane (top of implant submuscular) next week. My breast surgeon mentioned that implants under the muscle have more of a tendency to drop/sag over time because the muscle is pushing it down. I guess this would be a reason to go prepectoral instead, but I figure there could always be a future corrective surgery if the implant were to drop. Ugh... it's all so scary! I had to go under general anesthesia this morning for the excision because the incision was a semi-circle around the areola. It reminded me how much I hate the whole operating room thing and I'm not looking forward to more surgeries.

  • wondering44
    wondering44 Member Posts: 261
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    I had implants placed before breast cancer (sub-glandular). They were spectacular, but I would have liked a little more lift when I wasn't wearing a bra. I still felt like I had to wear a bra to push them up in clothes. I had the pre-pectoral with ADMs for the reconstruction. I did not do fat grafting. MY PS said they typically don't do it for their mastectomy patients at the facility I used for my reconstruction. My PS asked if I wanted a more cleavage look before we did the surgery. Of course, I went with a more cleavage look option. I absolutely love the look of them in a shirt without a bra. I only feel the need to wear a bra when I am at work out of courtesy to others. I'd run around without a bra all day at work if it were appropriate in my work setting. Yes, the reconstructed boobs look like I had implants placed.
    One thing to consider is that reconstructed breasts are not the same as getting a breast augmentation — so I learned after having both surgeries. My mastectomy removed the breast tissue, which created a more natural look for my pre-cancer breast augmentation. The mastectomy also removed the nipple sensation, which is a BIG bummer. My reconstructed breasts are very apparent in clothes that they are not real (I wear them happily - scars and all). Again, mastectomy reconstruction and breast augmentation are different. If you move forward with a mastectomy, try to get adequate information on the difference between your breasts now and mastectomy breasts. Natural breasts with implants are different from mastectomy breasts with implants. Do try to research it and discuss it with your PS. You want to be well informed of what you are giving up by choosing a mastectomy and reconstruction. I am not saying not to do it, but just throwing out a caution that you can't put them back on after they are gone...not even with reconstruction.
    If you want a more natural look, consider asking for input from others who have had autologous/flap reconstruction about their results. I posted a link below. I hope this helps some with your dilemma.

    https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/autologous-flap

  • coffeluver
    coffeluver Member Posts: 9
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    @wondering44 Thanks for responding to my question! I'm just curious as to why you say your post-mastectomy implants do not look real? This is what I'm worried about. Is it because there is visible rippling or indentation at the top (where the implant meets the top of the chest)? Or is it because implants look higher and rounder than real breasts? I have been to consults with 3 different plastic surgeons and have already come to terms with the fact that implants post-mastectomy will not look as good as my natural breasts. I just want to make sure I'm doing whatever I can to ensure the best possible result. In my latest consult, I was told that getting tissue expanders would end up with a better cosmetic result than direct to implant, even though I'm not going much larger. It allows them to make the pocket tighter, so less loose skin. But I still haven't found any doctors willing to do subpectoral. They insist that prepectoral yields a better or at least equivalent result.

  • snm
    snm Member Posts: 95
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    Hello there! I hope you get some advice from the others. Right now I have tissue expanders in that are partially under the pec muscles bilaterally s/p BMX. Only filled to about 400cc (ie B cup). I undergo implant exchange at the end of May. My plan is for nipple tattoo after that..i think..not sure if the nipple recon is really worth it or not. Not really sure how I will look but will try to remember to keep you posted.

  • wondering44
    wondering44 Member Posts: 261
    edited May 2023
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    coffeluver,

    My implants look like implants - "Or is it because implants look higher and rounder than real breasts?"

    I don't have an issue that they look like implants (my personal preference). If you are concerned with that result go back to the drawing board with your PS. You have options and time on reconstruction. Waiting and getting the right results is better than rushing through it and getting something you don't want.

    Best wishes to you on your results.

  • veggal
    veggal Member Posts: 261
    edited May 2023
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    I switched from subpectoral to prepectoral. They are fantastic.

    The subs were annoying with the animation deformity ANY.TIME.I.FLEXED. Super annoying. I also had so many ripples.

    i went prepectoral with a firm implant and had two rounds of fat grafting which “stuck” just fine. My BMI was 19.2. There was plenty of fat. Now I have nice looking implants, no animation deformity and no ripples at all. They will be six years old in September


    I would never go back to subpec. Never!


  • lillyishere
    lillyishere Member Posts: 773
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    I had BMX, subpectoral implants 3 years ago. PS recommended subpectoral and I went ahead with the surgery. I am thin, with no fat to be used in breast reconstruction and I selected the same size I had my natural breast. They look fake! When I exercise, they feel like Tupperware. One is dropping down a bit. PS suggested subpectoral because his theory was that the skin gets thinner with age (and anti-estrogen medications) and won't be able to hold the implant. I do need to cover up well when I wear a tanktop in the summer because you can see around the implant looks weird.

  • recoveringbelle
    recoveringbelle Member Posts: 23
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    Veggal, back here after 17 years, after having a left mastectomy w/ subpectoral implant reconstruction and r side subpectoral implant for symmetry. Now I have at least three ILC tumors in my R breast and need to get it removed too.

    I've always had that animation deformity on my L breast and hated it, but in 2006 I was just happy that there were such great reconstruction options compared to what my stepmother and others had faced. My PS was top notch and very proud of his work—and I went from always being an A (and a size 2) to having C cup breasts. So weird—got more male attention than I'd had in years!

    So, w/r/t tx now, I only learned last week, when I consulted w/ my plastic surgeon about my upcoming mastectomy on 9/7, that prepectoral was an option.

    He says that the "slope" of my L subpectoral implant looks great, but yep, to me it's always felt like one of those old footrests, like a cement cushion. And I "animate" all the time and so have tried to hide my naked breast in intimate situations so it doesn't squeeze in and freak my partner out (he'd never admit it, but I'm self-conscious about it.)

    The thing is, my PS seems to think getting both of mine to pre-pec will take three surgeries, but I asked, why can't (next week) he just remove the subpec implant and sew the pec muscle back up, then, my Surgical Oncologist does the mastectomy, then at the same time he assumes puts in a pre-pec tissue expander (after removing the now leaking implant since the biopsy they did last month). Then, in three months, I can have new pre-pec implants put in. Two major surgeries instead of three.

    If they look bad (after the nipple tattoos), then I can go for fat grafting (might give me a legal tummy tuck!). But otherwise, it's two major surgeries.

    I also don't understand why I have to have a tissue expander at all on my R side—why they can't just put an implant in—but not sure that I'll get an answer.

    I will say—the PAIN of the tissue expander in the subpectoral space was INTENSE. I told them I won't go through this again w/o guarantee of opioids if I need them, because last time, I really, really needed them—Dilauded, for 2 months. It hurt more than the mastectomy, by far.

    Would love input from y'all about this "slope" issue on skinny women and the fake-ness of pre-pec implants. I'd just love to be able to lean over and have my breasts be 1) symmetrical and 2) not squeeze in like I'm an fiberglass android.

  • coffeluver
    coffeluver Member Posts: 9
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    I also had a plastic surgeon tell me that I should get expanders instead of direct to implant with prepectoral, even though I would be getting implants around the same size as my natural breasts. He explained that it is about the integrity of the skin and he can make the pocket tighter if time has elapsed from the surgery to allow the skin to heal. There is a risk of necrosis if the skin is too tight around the implant right after the surgery, I guess. I would be especially concerned about looseness of the skin if getting prepectoral since those are more likely to show rippling.

    I'm still not sold on prepectoral implants and am still looking for a surgeon in my area willing to do the dual plane (under the muscle at the top with ADMs to support inferior pole). Fortunately, I don't have any cancer, just a high risk, so I can take my time in finding the right dr & procedure. For me, I think the potential for animation deformity is less of a problem than breasts sitting like shelves on top of my chest. Also, I read there are degrees of animation deformity & not everyone gets it. It is caused when the pectoralis muscle is over-released & attaches to the skin. So it seems to me that fat transfer could solve this problem as well if they can insert the fat between the over-released muscle and skin.

  • nume
    nume Member Posts: 81
    edited October 2023
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    I had prepectoral implants at the same time as the double mastectomy. It took few months but now I can sleep on my belly and don`t mind them anymore. I had BMI 21 at the time of the surgery, fat was not an issue, did`t need any transfer. I opted for anatomical shape, not cosmetical. They look natural, a bit droopy. I can`t feel the surface of the breasts but the surface of the chest(under the implants) feels normal, natural.

    My only complain is the weight. I would have wanted smaller size. I had 350ml

    XO