Alloderm vs. no Alloderm

FlGulfCoastGirl · August 2014

I am scheduled for a bi-lateral mast. next week with immediate reconstruction with tissue expanders and an Alloderm "sling". The plastic surgeon said during reconstruction the bottom of the pec muscles are detached from the rib cage, the expanders are placed underneath, and the Alloderm is used at the bottom of the implant to create a "sling" in the bottom area not covered by the chest muscle.

I met with another surgeon who discussed another option that does not use Alloderm, but rather cuts the pectoral muscle laterally in the middle of the muscle, the expander is placed under the muscle and the muscle is stitched back together, and never detached from the ribcage. This sounds like a more favorable surgery to me as I am athletic and want to retain my upper body strength, and leaving the muscle attached to the ribcage seems favorable, although I didn't really get clarification if that is accurate.

The first surgeon was under the impression that I will have radiation treatment after surgery (the one that recommended Alloderm). The second surgeon was under the impression that I may need radiation and was talking about delayed options. I am wondering if the second surgery would be possible prior to radiation treatment. Has anyone had the second surgery prior to radiation? Anyone want to comment on their opinion on reconstruction with vs. without. Alloderm? Or on immediate vs. delayed reconstruction?

P.S. I had a suspicious lymph node on my original pet scan, prior to neo-adj. chemo, which is why radiation may be recommended.

FlGulfCoastGirl · August 2014

P.S.

I am sorry I didn't provide a brief intro. I was diagnosed with IDC in March 2014 at the age of 28. I had a 4cm mass with satellite lesions and a suspicious lymph node on the PET scan. The pathology of my biopsy was ER+, PR+, HER2+, BRCA-. I competed neo-adjunct chemo, Perjeta and Herceptin treatments and will continue on Herceptin for a total of a year. Radiation has been recommended by one oncologist and the second oncologist said it depends on the pathology of my surgery, which is scheduled for next week. I am trying to make sure I am making my plastic surgery choice based on options available. I originally was only considering immediate reconstruction, but am looking forward to hearing your insights. Thank you!

ab1234 · August 2014

Wow. First, good luck to you in all of this and you are in "good company" on this forum.

I did not have breast cancer prior to my surgery; I have the BRCA gene and did a double MTX with reconstruction. I was a "candidate" for immediate reconstruction because I didn't have many of the issues you refer to...I wasn't going to have radiation....I was young and healthy and athletic. I chose to still go the expander route without alloderm which i am generally happy with. I was a competitive gymnast and still do tons of yoga/pilates and was somewhat shocked by the impact of my surgery on my pectoral muscles! It's been about 2 years since my implant surgery and while they look GREAT and generally feel great, the pectoral muscles act quite strangely. Not to the point that it stops me from doing anything but its "there" all of the time. And now my right breast is having significant wrinkling in the cleavage area; I am considering going back to look at my options for rectifying that but will definitely weigh the benefits against the downtime from additional surgery.

I have a very good childhood friend that is my same age and DID have BC and radiation prior to her double MX...she had to keep the expanders in place for much longer than I did...over a year I think? And while the exchange surgery was initially successful, about 6 months later her more radiated breast "dropped" and she was in the hospital for well over a week getting that breast taken care of. Again, the bright side is that she is now TOTALLY healthy and happy and doing triathalons.

So I would say that your questions about pectoral muscles are not unfounded and you should ask many more questions. If you ARE going to have radiation, I would pursue all options that will "strengthen" that skin for your final surgery. BEST of luck to you...you will get through this and be as strong as ever!

SpecialK · August 2014

The question of radiation issues with your skin may possibly be more important than the question of alloderm and mobility/flexibility going forward. Delayed recon after radiation is problematic, ask your breast and plastic surgeons about expanding, with over expansion, prior to beginning radiation, if you require it. That way you are not asking radiated skin to be stretched - from what I have seen if you delay expander to implant type recon you have about a 50/50 shot at success. Many plastic surgeons will only do flap reconstruction after radiation and will refuse any type of recon that stretches the skin. Another reason some docs use allograft material to create slings is for support. In order to replace breast tissue of equivalent size the silicone implant needed can be quite heavy, so alloderm slings are used to help support that weight. Ask your plastic surgeon to let you hold an implant that is approximately the same size as your breast and you will see what I mean. I would also ask your plastic surgeon where he plans to make the incision on your skin, as this may also dictate whether allograft material is used, and where. I do have alloderm and my incisions are IMF, not on the front of the breast.

DiveCat · August 2014

I never had a cancer diagnosis, and had a PBMX due to high risk, with immediate reconstruction with implants and Alloderm. I am very pleased with it, as the Alloderm helps recreate the definition of the IMF that can be destroyed by the breast surgeon, and adds some internal support. It is stitched at bottom of pectoral, at ribcage, and at serratus anterior muscle. My incisions are in IMF (I kept nipples) so you can't really see them. Immediate recon with Alloderm is considered a newer technique still and a lot do not do it.

By the way, I am very athletic and have no issues at all with my athletics now (running, hiking, weight training, kayaking, scuba diving and lugging heavy tanks and gear around, etc), though of course my own experiences are just my own, some women do have issues depending on their activity. I honestly do not even think about my breasts really anymore now that I am healed, it often slips my mind I even had surgery.

I will just admit I have not heard of the technique (incision in middle of muscle) your second surgeon proposes. However, it does not make any sense that the muscle is not lifted by the second surgeon really as the muscle needs to be lifted off the ribcage to put the implant in between the muscle and the ribcage, even if his method of incision is different. So your muscle will still be lifted off ribcage. Usually what is done in traditional implant reconstruction is the lower part of pectoral is lifted, as well as sometimes part of the serratus anterior muscle on the side for coverage. The implant is slipped underneath and the muscle acts as a "support" to keep the implant there. Some use Alloderm as a sling even with expanders. But, even if your surgeon does not lift the muscle from the bottom, the muscle is going to have to be "lifted" from the ribcage to make a pocket/room for the expander/implant. So I am not sure what the benefit of cutting across the muscle is; that to me sounds a little riskier honestly than lifting the pectoral from the bottom off the ribcage, as now you have both a cut into the muscle across it that needs to heal properly as well as the normal lifting of the muscle off the ribcage to make room for the expander/implant. I would also ask how that technique allows for the implant to settle properly, wouldn't the muscle at bottom squeeze the implant upward and not allow it to take on the breast shape?

I agree however that the risks of radiation and implants should be the primary thing for discussion right now; expanders put in before radiation may be a better option in that respect whether you get Alloderm or not (Alloderm may reduce risk of some of complications with radiation & implants). Then after you have healed after treatments, you can switch to implants. As was said above, implant recon is contradicted for radiation patients, so many PSs prefer to do flap surgeries.

FlGulfCoastGirl · August 2014

Thank you so much for your detailed responses. I am meeting with two plastic surgeons before my surgery and will likely slightly delay reconstruction-until I have healed from the masectomy but before potential radiation. I really appreciate the personal experiences shared-you are all so wonderful to take the time to reply. I feel like there should be a breast cancer "coach" provided to help you navigate through all the alternatives and questions that should be asked! It is overwhelming and frustrating to realize that I haven't been asking some of the questions I should have been asking! Thank you again for sharing your insights!!