Over the muscle breast reconstruction?
Breast reconstruction using tissue expanders and implants are done under the pectoralis muscle. This is either with or without the use of acellular dermal matrix.
If tissue expanders and implants must be used as your mode of reconstruction, as opposed to using your own tissues, the appropriate technique is ONLY to go under the muscle. This will provide the most tissue coverage and support for the implant. Having the appropriate tissue coverage is key for the best long-term result cosmetically-speaking, as well as to protect you from contamination, infection, skin necrosis, and extrusion of the implant.
Going over the muscle for breast recontruction`
By no means is going over the muscle the recommended technique; this is because a mastectomy thins out your skin and will make the implant easily palpable and maybe visible! Every effort is made to camouflage the implant as a result including going under the muscle and using ADM (organ donated skin). There are a small number of surgeons trying the over the muscle technique, it is not intuititve that this would provide you superiror results.
Reconstruction after mastectomy
is usually done under the muscle with ADM's to help protect the implant. If you choose to go above the muscle, my biggest concern would be the quality of the skin flap (how thick is it and how healthy is it) and would require use of a textured anatomic implant that doesn't move. Make sure your surgeon explains all of the pros and cons of implant placement before having this done.
Sagging or rippling - which is more likely
Given the amount of skin removed with the mastectomy, sagging is probably not your main long term concern, but rather rippling i more likely to be the problem you encounter. However, this can be effectively treated for most patients with fat grafting. I would suggest discussing your concerns with your surgeon - best of luck with your reconstruction!
Placing implants above or below the muscle after reconstruction
Hi and thank you for the question. In Traditional breast reconstruction implants are placed below the muscle. Over the past several years there has been considerable interest in placing implants above the muscle. This is referred to as pre-pectoral reconstruction.
Another plastic surgeon in this forum suggested that the results are predictably awful. I would suggest that surgeon is giving you poor advice. The fact is that many highly competent plastic surgeons are offering this technique and achieving excellent outcomes. I think this demonstrate the point that not all advice is good advice. Before you commit to this journey make sure you do your homework. Find a plastic surgeon who specializes in breast surgery and can show you outstanding results. Good luck to you.
Having a double mastectomy. I have elected to go with over the muscle. Will the implant eventually sag?
The majority of mastectomy patients are left with a very thin soft tissue layer for a reason, the surgeon is trying to cure a disease and wants to remove as much breast tissue as possible. With that thin layer I cannot imagine even considering placing an implant in front of the muscle, The results are predictably awful. But it may be that something is different about your surgery that we are not aware of and your surgeon is, so I think you will need to ask your doctor this question. I do hope your doctor is a board certified Plastic Surgeon with extensive experience in this procedure. If not I would strongly urge you to see another consultant or two before going through with this plan.