Placing the implant under the muscle (sub-pectoral) is the more long standing form of reconstruction and the one done by the largest number of plastic surgeons, although interestingly it replaced placing the implant above the muscle many years ago before the use of acellular dermal matrix, as many patients had capsular contracture or were not candidates. This type of reconstruction may involve direct to implant surgery if you wish to stay on the smaller side, and are a good candidate as determined by your surgeon - as you are limited to whatever size implant will fit behind the muscle. Not all plastic surgeons perform direct to implant reconstruction. For greater discretion as to size, it is more common to have the use of explanders under the muscle to stretch them to accommodate a larger implant. Some plastic surgeons also prefer this method as they feel it provides better control and a better aesthetic result. Allograft is also commonly used in sub-pectoral reconstruction for support. The complaint about sub-pectoral placement is both the expansion process and the implant distortion by the animation of the pectoral muscle. This varies from patient to patient as we all have different muscle thickness and tolerances. Placing reconstruction above the muscle (pre-pectoral) under the skin with allograft slings, has more recently become available as an option. This approach can involve both expander to implant or direct to implant as well, but is again limited to candidacy, skin tolerance, and skin integrity. If you have thin skin or poor vascularity you may not be a good candidate for this type of reconstruction, and there is some thought that the implant may obscure local recurrence, so more thorough surveillance with MRI is required to detect it. Also, location of your tumor and the proximity to the skin or argin is an important consideration as to whether this is the right type of reconstruction for some. Direct to implant - whether sub-pectoral or pre-pectoral may result in fewer surgeries, but with both procedures there can be a need for future fat-grafting to smooth out edges or dents, and there can be complications that require surgery again in any reconstruction choice. There are pros and cons to all forms of reconstruction so you should thoroughly discuss with your plastic surgeon how these apply to you as an individual, but be aware that because not all surgeons provide all reconstruction options, including autologous reconstruction like DIEP or other flap surgeries, you may have to actively search for a surgeon who performs the type of reconstruction you wish to have.

SpecialK did a great job explaining everything. If you opt for implants, pre-pec definitely has the advantage vs under pec. So why am I posting? I’m posting because I’m worried you’re being rushed into a decision by your dr and the timelines for the other events you’ve got going on. BC is urgent, but it’s not an emergency like a rupturing appendix. The decision you’re making does require thought, not just accepting whatever procedure they push you toward or choosing the one that is fastest/easiest.

You need to consider your age - are you young enough that you’ll likely need to replace implants at least once maybe twice in your lifetime? This can be problematic if 10-20 years down the road when you consider you’ll be 10-20 years older with all that entails.

What size are you today? - will the implants be able to approximate the same size and look? If not, you may want to investigate DIEP or SGAP flap options. Many women who are size 18/20 have DIEP/SGAP done no problem. Even with prior abdominal surgery (I had 2 different abdominal surgeries previous to DIEP.) (Here’s a link to the center referred to as NOLA on the BCO boards-check out their before & after including women above a size 16: www.breastcenter.com ). I’m betting your PS does not do natural tissue recon and that may have been part of his reasoning.

How do you want your breasts to look/feel? Implants do not feel like natural breasts. Flap recon breasts (no implants) do. Depending on the talent of the surgeon implant breasts may look natural but then they may not. Recon using implants is not the same as breast augmentation. Without the recon most of us would be concave across the chest. It’s a very different surgery with different outcomes. Its important to see plenty of before and after photos of patients who have had the same surgery by that PS.

Before & after photos tell quite the story about a PS’s abilities, skill and talent. If you look at before and after photos and you would not be happy to have the results in the photos for your self, then keep looking for another PS. The ideal (and fully attainable) outcome is for you to be happy with your recon, able to look at yourself in the mirror everyday and not be sad, able to confidently wear a bikini/bathing suit, able to be intimate with your significant other with your shirt and bra off. The term happy means just that-genuinely happy, not just happy considering you had BC and it could be worse.

Don’t let anyone rush you. Take the time to thoroughly investigate your options and educate yourself. You and only you are in the drivers seat in making these decisions. Us ladies here on BCO are great resources with all the experience/knowledge we have collectively. Don’t be afraid to reach out for advice, facts, and questions!