Nov 27, 2020 03:22PM exbrnxgrl wrote:
When you say direct to implant, do you mean step reconstruction without tissue expanders?
If you've had or will be having a mastectomy (or in some cases, lumpectomy), you're likely facing decisions about whether or not to have breast reconstruction, and if so, what type and when. Deciding whether or not to have a breast reconstructed is a very personal choice. Take the time you need to learn about how breast reconstruction might affect you, both emotionally and physically, before you decide to have the surgery.
Learn about different surgical options and the medical and personal issues around breast reconstruction.
Intro medically reviewed by: Brian Wojciechowski, M.D.
Last review date: November 22, 2020
Posted on: Nov 27, 2020 01:01PM
Posts 1 - 30 (45 total)
Nov 27, 2020 03:22PM exbrnxgrl wrote:
When you say direct to implant, do you mean step reconstruction without tissue expanders?
Nov 27, 2020 08:37PM hnsquared wrote:
hello peggysmom...I had direct to implant, so implants put in at the time of mastectomy no tissue expanders. My understanding is that not everyone is a candidate for direct to implant for various reasons but one reason you may not be a candidate is if you want to go larger. I was happy being about the same size or smaller. If I wanted to be larger I would have needed to go with tissue expanders.
I’m happy to answer any questions if you have them
Nov 27, 2020 10:46PM exbrnxgrl wrote:
I should add that I had one step implants placed over nine years ago. Another important element that may dictate the size of your implants is whether or not you have sufficient skin to cover the implant without expansion. If you’ve had a skin sparing mx, you can go about the same size as your natural breasts.
Nov 28, 2020 08:15AM dtad wrote:
Hi everyone. I had direct to implant, no tissue expanders almost 6 years ago. I went from a DD to a full C. It took me awhile to get used to being smaller but for me it was more than worth it. You not only don't have to have tissue expanders but you don't have to have a second surgery. Hope this helps...
Nov 29, 2020 11:12PM peggysmom wrote:
Hi! Thank you all for your response! yes, I mean 1-step direct to implant (without expanders)
hnsquared and exbrnxgrl: This is why I'm confused, I do NOT want to go larger. I'm currently a DD and the PS flat out stated "they don't make an implant big enough for you". Which I found quite surprising. I guess even with a skin/nipple sparing mastectomy he will not put in a 600-800 cc implant without expanders, and tbh i'm confused about that.
If my skin "pocket" is big enough to hold the implant why would there be a risk of post-mastectomy necrosis? Not only that, the PS said the size he WOULD be comfortable with immediately would be "deflated" and i'd have "extra sagging skin". Which is weird, im 40 with perky DD's (oxymoron, I know). Honestly, I've been told he's the best, but we just weren't seeing eye-to-eye on anything.
dtad: Thanks for sharing! I'm also a DD and really was a full C the majority of my life- with weight gain my breasts got much bigger. I'd be more than happy with a full C. May I ask you how many CC's was your implant? I'm 5'10" 200 lb and just want to remain "in proportion".
Nov 29, 2020 11:38PM exbrnxgrl wrote:
Forgive me but since it’s been more than nine years since my surgery but I do have a vague recollection of my ps saying that he didn’t recommend larger than about a C cup for one steps. My implants are 457 cc’s. They are a bit wider than my native breasts were and I generally wear 36C bras. Most patients also get some type of internal support such as Alloderm, which creates a supportive sling under each breast. I wouldn’t hesitate to question your ps to understand this better.
Nov 30, 2020 10:45AM - edited Nov 30, 2020 10:48AM by DiveCat
I was direct to implant in 2014. I was a natural 30E-32DD (depending on brand and stretch of their bands) and remained so after surgery (and every surgery since - yes, I was direct to implant but I have had three different sets of implants since). For me that meant implants that were roughly 450g or so at initial surgery but what that means or looks like depends on the profile and width of course (my current ones are a bit more than that but different width and profile, etc). Also to note, I was subpectoral with Alloderm slings. I was not interested in going bigger but would have been okay a bit smaller - turned out I ended up at the exact same (though of course implants of course look and sit a bit different than I did naturally).
I would talk to your PS more to understand. Could be they are just concerned about stressing tissue and plan could be to put a smaller implant for now but perhaps when you heal a bigger implant may be possible. My sister for example is similar size to me and was supposed to be direct to implant but during surgery they decided (using dye) that her tissue blood flow was not reacting well enough and were concerned it would affect nipple survival. She was going prepectoral so my understanding is they they were particularly cautious about the skin integrity. So they left her flat for 2-3 weeks to heal, then she got smaller implants, then about 6 months after that larger implants along with fat grafting.
I know generally you do a direct to implant to avoid “additional surgeries” but it does not necessarily mean you are one and done. Skin integrity is important so perhaps in a few months or a year or two a revision to larger implants will be possible.
Nov 30, 2020 03:47PM hnsquared wrote:
peggysmom....I was a 34 DD prior to surgery and I’d say I am the same after. Like exbrnxgrl said mine are also a little wider than I was naturally. I would have been fine being a c if it would have turned out that way. I did know going into surgery that the plan was direct to implant but if there were any issues with blood flow or anything else while they were in process that the plan could change. I would ask the plastic all the questions and then get a second or third opinion. You want to feel good about your decision. Also... as die cat said it’s probably not one and done. As they settle tweaks may need to be made.
Get all your questions answered. I wish you the best. Let us know how it goes
Nov 30, 2020 08:14PM - edited Nov 30, 2020 08:16PM by peggysmom
Thank you all so much, this forum has been so very helpful! I can't tell you that enough times.
I sincerely wish he had talked to me just as you have explained- but it wasn't like that. Purely he said he wasn't comfortable using a large implant.
Oh yeah, initially he said "First breast reduction and then few months later mastectomy with expanders". After I explained that I'm not interested in reduction first- "i can give you deflated with sagging skin as long as you are aware of the outcome... I encourage you to get a second opinion they may have a different threshold.... if you want to move forward with me call my office" The consult was less than 30 minutes. I'd say 15-20 minutes. He also wouldn't commit on what "size" i'd be should we go the flap route.
Many women on this site say we see our PS more than our surgical oncoligists- even if Dr. G is the best, not sure our personalities mesh for the long-run and the inevitable touch ups etc.
I'm really hoping things go well this Thursday with my 2nd opinion doc, will keep you posted!
Nov 30, 2020 08:56PM DebAL wrote:
boy Peggy, I hope it goes good for you Thursday too. Its so important to listen to your gut and don't settle until you are comfortable!
My appt with PS was pretty involved. We discussed direct to implant but I was well aware that would be determined by blood supply etc at the time of surgery. I ended up with expanders which was totally fine with me. I couldn't ask for a better outcome cosmetically.
Don't go into this without getting all of your questions answered. Best of luck!
Nov 30, 2020 09:01PM exbrnxgrl wrote:
No doctor is “the best” unless you are comfortable with her/him. For me, feeling completely comfortable with a doctor is just as important as their skill level. And never underestimate the value of a second opinion
Nov 30, 2020 09:41PM - edited Nov 30, 2020 09:58PM by muska
Hi peggysmom, in addition to what was already mentioned on this thread please keep in mind that most of the times the implant goes under the pectoral muscle. The larger the implant the more they need to stretch the muscle. With direct to implant if a large enough implant is inserted under the pectoral muscle without prior stretching I imagine the discomfort could be significant. If they put it above the muscle I am not sure how they keep it in place especially if it's a rather large implant. With sub-pectoral reconstruction there's usually an Alloderm sling that was already mentioned and the muscle itself helps keep it in place
I was 36DD or DDD before surgery. I wanted to go to C. I got 500ml implants but that was after the expanders. I am 36C now, 5’4’’ and 145lb
Dec 1, 2020 10:17PM hnsquared wrote:
muska...I think they are doing direct to implant prepectoral more often now. My direct to implant is pre pec and they use alloderm to create a sling or internal support for the implant. Eventually my body will create collagen that will form with the alloderm. I know my plastic does all the direct to implant pre pec
Dec 2, 2020 11:19PM hnsquared wrote:
peggysmom...I can’t remember what size but I’ll find that paperwork and post. I was 34DD going in and I’m still 34DD. My new breasts are a little wider than my natural ones were...I imagine it’s because implants are shaped that way.
Dec 5, 2020 12:05AM - edited Dec 5, 2020 12:06AM by MinusTwo
Peggysmom - Is there some reason you don't want to go with TEs? I think the implants could be larger if you go that route.
Below is a great thread about implants. If you read Whippetmom's header and provide the information asked for, she is truly a 'breast whisperer'. Many of us have appreciated her expertise and taken her thoughts into meetings with our own plastic surgeons. She doesn't check in every day anymore, but her information is invaluable.
BTW - how far along are you in the process?
Dec 5, 2020 08:08AM dtad wrote:
peggysmom...sorry I cannot remember how many CCs my implants are. My PS told me she would make them as big as possible so I really didn't care. My one piece of advice would be to find a PS that has experience with direct to implant reconstruction because they don't all do! Good luck
Dec 5, 2020 11:27AM Beesie wrote:
My reconstruction is sub-pectoral (pre-pectoral was virtually unheard of back when I had reconstruction) and I had an expander, so my experience isn't relevant, but as you are making your decisions about what type of reconstruction to go with, there is one thing I want to raise based on the discussion.
Sub-pectoral vs. pre-pectoral. When I was deciding on my reconstruction, I was concerned about screening for recurrence and/or a new primary. My BS assured me that with sub-pectoral, because the implant is placed behind the chest muscle, the chest wall is in effect pushed up to be right behind the skin. So both a skin recurrence and a chest wall recurrence (or new primaries) will be very easily detectable as a nodule under the skin. I have found that with the smooth firm surface of the implant I do notice every tiny lump or bump that develops - fortunately I've had nothing more than little lumps from the stitches and the occasional small skin lesion. But I'm very confident that if a recurrence or new primary were to develop, I would notice it even if it was only 1-2mm in size.
What I don't know, and put out there for your consideration (and expertise), is how chest wall recurrence/new primary detection would work with pre-pectoral implants, since usually no imaging is done after a MX.
Dec 5, 2020 12:24PM hnsquared wrote:
hey peggysmom...I am so sorry I didn’t get back to you with the cc’s of my implants. I thought I had that info but couldn’t find it. I was going to call my plastics office but I see you have already been to your appointment. I’m happy to get that info if it will be helpful.
I had nipple sparing and skin sparing on both breasts. I was expecting to go with tissue expanders because that was what everyone I knew who went through this got. My surgeon sent me to her preferred plastic and direct to implant was his recommendation for me. We also talked about expanders because if there were issues at the time of surgery we might have had to go that way. We also talked about reconstruction with my own tissue but I wasn’t interested in that.
These are all such tough decisions at a time when you are bombarded with information. Keep us updated and let me know if you have any other questions
Dec 5, 2020 12:53PM - edited Dec 5, 2020 12:57PM by peggysmom
hnsquared: No worries! Thanks so much! The academic center where i've had my appointments may be too "conservative" with their approach to reconstruction. The issue comes down to volume. Apparently there are some medical centers with approved protocol for larger implants (Mentor, up to 1400) so may be exploring that option.
MinusTwo: The way i've understood it, the issue will still be volume with or without expanders. Routinely silicone implants only go up to 800 cc. I'm a DD. I guess saline could be a consideration, they are inflated on the table to 1000 cc in the OR.
Beesie: Women don't get mammograms for screening after mastectomy, because there should be no breast tissue left. Pre/Retro positioning isnt really an issue for women post mastectomy with implant based reconstruction because US and MRI is used for eval if their is any concern for recurrence. Pre/Retro positoning may affect women with augmented breasts in terms of screening, and yes it's true there are ways the tech can position the tissue with retropectoral implants for mammographic eval of the actual breast parenchyma (implant displaced views).
Was very disappointed in my appt and time is not on my side. The sense I have from the PS at my iinstitution is they are very "vanilla" and not willing to do anything except tried and true techniques even if it means I as an almost 6' woman with large frame will not have reconstructed breasts that are proportional to my frame. So unfortunately I'll have to look elsewhere. For my volume, it seems i'm stuck at least with what PS at my institution are offering me. I do know other instututions "stack" flaps (i.e. DIEP and PAP) but when I suggested that the PS was not having it. He kept going on and on about how it's a long 12 hr surgery. In my honest opinion, I felt they were discouraging me from flaps NOT because it's in my own best interest but rather his/their best interest as it's a technically challenging long surgery for which they are not reimbursed appropriately for their time/effort. Much easier to place pre-pectoral implants 45 min -1 hr each breast.
At this point i'm seriously considering a temporizing measure just to get this wickedly abnormal tissue out even if it will leave me with a large defect. I can have lumpectomy of the 10 cm, clear margins. get the SNB and keep looking for a center that will help me reach my goals: Bilateral Nipple Sparing Mastectomy with direct to implant (large implants) or stacked flap reconstruction. Doesn't seem like a tall order. And if they are worried about nipple necrosis, a nipple delay procedure could be done. I'm not a surgeon but that's my goal.
Dec 5, 2020 02:07PM Beesie wrote:
peggysmom, yes, I realize that women who've had a MX don't get mammograms. And I understand that if there is a concern, someone with implants will have an ultrasound or mammogram. So to be clearer, my question is "does pre-pectoral make it more difficult to find a chest wall recurrence?" I have sub-pectoral so my chest wall is right under my skin, making even the tiniest nodule against the skin or chest wall very obvious to me - it will be palpable at 1mm. But for those who have pre-pectoral implants, the implant is on top of the chest wall, so could a chest wall recurrence be missed, at least until it's quite a bit larger and perhaps causing discomfort or making itself noticeable in some other way?
The question of screening with implants comes up a lot on this board. It's a big concern for a lot of women planning this type of reconstruction. I can answer for sub-pectoral based on my own experience (no screening, tiny nodules will be very noticeable by feel) but I don't know the answer for pre-pectoral and I have never seen anyone provide the answer.
Dec 5, 2020 04:51PM peggysmom wrote:
My post was accidentally deleted. No, pre-pectoral implants do NOT hinder detection of chest-wall recurrence. Although this area is not clinically palpale or seen with ultrasound if implants are above the muscle, MRI and PET easily demonstrate a recurrence
Dec 5, 2020 05:31PM MinusTwo wrote:
PeggysMom - asking again -
What is your diagnosis? How far along are you in the process? Have you had neoadjuvant chemo? Do you know if you will have chemo after surgery? Will you have rads? Are you HER2+, so will you have Herceptin?
Dec 5, 2020 05:49PM - edited Dec 5, 2020 06:02PM by DiveCat
I understand the point Beesie is making (or asking about), and what you are saying. Yes, if you are getting regular MRIs or PET chest wall recurrences may be detected.
But few end up getting regular MRIs or PET scans ongoing for years, etc though the chance for recurrence remains (of course that risk varies depending on various factors including your ex, the oncotype, personal risk factors, etc). My own mother didn't get regular screening again (following her initial treatment and “remission") until she had her metastatic recurrence some years later.
Being palpable by your own fingers may be exactly what indicates a need for MRI or further screening, or else it may go undetected for some time.
It is definitely something to consider. Like Beesie mine are sub-pectoral (and like her, pre-pectoral was relatively uncommon then). However, my BMX was prophylactic.
I can easily feel with my own hands any irregularities under my skin. When I had chances to go pre-pectoral with revisions I denied doing so as MX can never guarantee to remove all breast tissue and I want it to be as close to surface to feel as possible. Before my MX I did get MRIs as high risk screening but protocol/guidelines where I am is I no longer do once I had my BMX (which is part of why I did it though as the screening took a mental toll for me).
My sister on other hand went pre-pectoral and accepts the risks that if there is an issue, detection may not occur early (she is also a prophylactic patient though).
If you are choosing pre-pectoral, I think you need to be very certain of what kind of ongoing screening will happen - if you aren't going to be a candidate for MRIs for example on a regular basis, will that or will it not factor into your decision
Dec 5, 2020 06:29PM - edited Dec 5, 2020 06:35PM by peggysmom
MRI's for implant integrity are obtained every 3 years. These are special silicone suppression sequences that typically do not include contrast. Your physican can choose to order it with contrast and request in the comments that the radiologist also evaluate for recurrence
Also- most recurrences are near the site of original cancer. If a woman has a far posterior cancer or anything abutting the chest wall she likely would not be a candidate for pre-pectoral placement.
Dec 5, 2020 08:43PM Beesie wrote:
"MRI's for implant integrity are obtained every 3 years." In theory, yes. In reality, not so much.
I appreciate the answer. I always suspected that chest wall recurrence or new primary detection would be more difficult with pre-pectoral, but never had that confirmed by a doctor or anyone here who was told this by her doctor. Given this, I'm sure it's true (or hope so, anyway) that if someone has cancer close to the chest wall, the surgeon would not agree to pre-pectoral implant placement. But as DiveCat points out, recurrence isn't the only risk - there always is a small amount of breast tissue left after a MX, and as a result we all face an approx. 1%-2% risk to develop a new primary breast cancer, even after a BMX. The risk might be higher for those with a genetic mutation or strong family history. I'm glad that next time the question comes up on the board, I can answer, although I think my wording will be "YES, pre-pectoral implants DO hinder detection of chest-wall recurrence. This area is not clinically palpable or seen with ultrasound if implants are above the muscle, however MRI and PET easily demonstrate a recurrence."
peggysmom, I didn't mean to take your thread off track. I raised the question because I think it is an important consideration for anyone deciding on their reconstruction choice, as you are in the process of doing. To DiveCat's example, with an awareness of how pre-pectoral implants affect the ability to detect the development of a chest wall cancer, some people (DiveCat, for example) will choose to not pursue this reconstruction option, but for other people (DiveCat's sister, for example) it's a small risk that they are willing to take. Awareness is key so that everyone can make an educated decision, based on their own priorities and risk tolerance.
DiveCat, nice to see you!
Dec 5, 2020 08:57PM peggysmom wrote:
Beesie, in the context of breast-imaging for identifying recurrence or new primary I stand by my statement:
"NO, pre-pectoral implants DO NOT hinder detection of chest-wall recurrence. ALTHOUGH this area is not clinically palpable or seen with ultrasound (unlike retro-pectoral implants) MRI and PET easily demonstrate a recurrence."
If the appropriate imaging is obtained, we see it.
And yes, let's get back to the original topic.