Over or under pec muscle

I have a combo and I'm not really sure all of it but I had my surgery last week January and am very happy so far. As for pain, I have a low threshold so you can't really go by me. Plus all the medical professionals involved in my care have said what an outstanding job my BS and PS did. I  am going through chemo now and won't have exchange til July or August.

The way the PS put it to me was once they are in there and see what's actually going on, they make the decision then.

For me I just turned 47 but was a smoker so that was a factor.

Hoping for the best for you ……. 

I didn’t really look at pictures or question my PS’s choice. I knew he was a great PS that is up to date on the best procedures, and I wanted to get the surgery scheduled ASAP since I had a small window of timerecommended by my MO after I finished chemo to get it done.

I have pre-pectoral implants. They do not look like balls on my chest. Instead, they are very natural looking... almost to the point that I love them more now than I do before the doublemastectomy!

Beesie- That's a great piece. I'm going in for some revisions Friday and that seals my deal.

Mother-Over the pec has the potential for more (for lack of better words) rippling on the chest wall that would necessitate fat grafting. Under the pec for some has a lot of animation. Like when I'm lifting weights in the gym.

My surgeon will do either if tissue is stable but prefers under the pec for appearance as the rippling can be very unsightly; she showed me some photos. Then when you get into fat grafting to “fix it" it can take several procedures to get desired result.

I can't speak to the comfort level between both as my implants on my side that didn't end up with contracture feels great to me. But my other side is tight .....getting that fixed Friday.

Good luck on your decision wishing you an easeful procedure whatever your decision.

Motheroftwo36 I had nipple sparing with immediate reconstruction. My PS did a kind of combo type where she put the leading edge of the implant (towards the center of your chest) under a small amount of muscle. The majority of the implant is above the muscle. So I don't get any strange movement when I flex. I am really skinny right now so I would look better if I had a little meat on my bones. I can see some ripples on mine but it isn't much and quite honestly these foobs look better than what I had before. I am usually someone who researches everything but funnily enough on this one I just went with whatever my PS said because I really trusted her judgment. Does your PS have images you can look at of their work?

Mine are under. It perhaps restricts push ups a bit, but full disclosure...I sucked at them before as well. Other than that, I have not had problems. I am a firefighter/paramedic, and I do still have the strength I need for it. My biggest challenge is that bathing suits fit weird. It is a challenge trying them on. I do think that overall, mine look very good; better than my previous breasts, to be honest. I had a local recurrence and because my implants are under the pec, I was able to feel the recurrence when it was still small. It scares me to think how big it might have gotten if it were under the implant. Local recurrences are rare after BMX, but low risk does not equal no risk. There is no screening such as mammograms after BMX unless you feel a lump.

I was doing research today on something else related to implants, and came across this article on the mesh. It weighs some pros and cons of it and some unanswered questions. (I do have a mesh sling with mine). https://www.philly.com/health/breast-implant-reconstruction-surgical-mesh-cancer-mastectomy-fda-study-20190401.html There are a lof of articles posted in the last few days about various implants because of FDA hearings. They may help in your discussion with PS.

hi ya'll, first I want to say that I just barely skimmed the article that was posted above because of where it was from philly.com!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! The Inquirer post or whatever! NOT REAL NEWS IMHO

I am a surgical nurse and it was not in a medical journal and I work in the operating room and have for the last 21 years. I get all of my info from factual medical journal and RESEARCH articles not just what you can find on the internet. Do not let that stuff scare you. We have to do a research class in Nursing School for a Bachelors of Science in Nursing four yr degree and there are very strong stipulations for research and that article had none of them, no abstract, nothing because it was just an "article" and could site no research! Put no faith in such articles.

I went with over the muscle and I have never been happier. Like some have mentioned previously, I feel that after my reconstruction I look better than before. My risk went down to 1-3% I think with my mastectomy and I did nipple sparing bilateral. Based on my age and health, I am 49 active, healthy, non-smoker, no diabetes or other conditions, my PS recommended the over.

https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm241086/htm My implants are shaped textured. I took the risk as the numbers are below 500 across THE WORLD and the number that have actually died are less than TEN! The cure if you get BIA-ALCL is remove the implants. Simple enough and alright by me. I am young so I wanted the more natural looking implants that the alloderm would "grow" into and my tissue into that.

Also to note, if you read in above article it shows the percentages of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is usually found near the breast implant, contained within the fibrous scar capsule, and not in the breast tissue itself.

I had a mastectomy so a) I don't have 97% of my breast tissue b) I have the alloderm completely OVER the entire implant and c) studies have shown the body doesn't form the capsular contracture around the alloderm because it is NOT a foreign body like the implant is. The Alloderm used to cover my implant is what is routinely used in breast reconstruction. Technically it is called ADM for acellular dermal matrix. It is a biologic mesh-like material derived from animals or donated (cadaveric) human skin. Alloderm is a human product and is the most widely used ADM. It is used in many different types of reconstructive surgery not just breast reconstruction. Before being packaged for use, it undergoes a multi-step process that removes all the cells that can lead to tissue rejection: even though it comes from another person, your body does not reject Alloderm because the immune cells are removed. Alloderm essentially acts as a scaffold and over time your own cells grow into it.

This was a HUGE selling factor for me as I see patients returning back to surgery for removal of capsular contractures around implants that make them rigid and hard and implants are not aesthetically pleasing any longer and the patient wants them fixed. These were mostly augmentation cases where the patient had implants for reasons other than cancer. Knowing that I won't get capsular contractions is a huge plus. I do need to go back and look at the research and see what number of patients that got diagnosed with BIA-ALCL were post breast cancer surgery patients and what number were from augmentation surgeries.

My big concern with under the muscles was also the PAIN. I am a BIG BABY and I hate pain and I have had a lot of surgeries from injuries in the military.

https://opmed.doximity.com/articles/pre-pectoral-breast-reconstruction-a-hot-topic-at-asps <---some of you might find interesting

Very personal decision and ultimately your own. I wish you luck in deciding but go with the decision that YOU are most comfortable with.

Find a PS that is experienced in doing over the pec muscle. In under the pec muscle they release your pec major from your ribs and sew it to aloderm to form a pocket. Your pec major will never work the same again. I have many many problems with my upper chest strength because under pec was all that was available at the time. Also do not go with textured implants because the FDA is thinking of banning them. Better to not have to deal with that down the road. I am currently looking at having my textured implants removed and I am not sure how that is going to affect my pectoral muscle.

having the implant under my pec muscle has affected my ability to do planks, my range of motion over my head, swimming upper body strength and shoulder mobility.

I know that you don't want to delay surgery to get another opinion and find someone more experienced but it is a a very permanent procedure.

The reason that over the implant isn't always great is purely because the skin is so so thin from removing all the breast tissue. They fold alloderm ( or sometimes a mesh) to make a pouch and then place the implant over the pec but under the alloderm. They have to fold the alloderm from a flat sheet to make it into a perfect shape to go over the implant. The skin adheres to the mesh or alloderm to form a pocket and can dimple because the skin is so thin.

With under the pec the top part is flatter because it is being pressed down with the pec muscle. There is a much smoother appearance. It compromises shoulder action because the pec muscle is no longer in the anatomically correct position and has strain from the implants.

Neither procedure is a walk in the park and in most cases it doesn't look like a california boob job. There is uncertainty going in either way. Also there is controversy over the implant itself because of the body reacting with the surface of the textured implant in some cases causing inflamation and in what they are claiming now a rare form of cancer.

I had so many ripples with the subpectoral implants. They were so ugly. Now I can't make the pre-pectoral ripple at all, no matter how I try. I will add that I had fat grafting. 

Definitely find a surgeon who is really good at it. I was lucky to have stumbled upon my surgeon (#4). 

Good luck!

https://opmed.doximity.com/articles/pre-pectoral-breast-reconstruction-a-hot-topic-at-asps Here is an article about pre-pectoral implants for reconstruction. PS first started doing it this way in the 70's but the lack of technology they had back then caused complications so PS abandoned that technique.

https://journals.lww.com/prsgo/Fulltext/2018/06000/The_Evolution_from_Subcutaneous_to_Prepectoral.18.aspx - This article describes the evolution of BR with implants.