What considerations are there for implant over muscle reconstruction after a double mastectomy? (Photo)

I had a dbl mastectomy in Nov, 2015. The original plastic surgeon inserted tissue expanders below the muscle with alloderm slings, and inflated them to 490 cc. I've moved on to a second (board certified) plastic surgeon who recommends changing to an over-the-muscle reconstruction with alloderm wrapping of the implant. I'm "pigeon breasted" and he explained that my sternum is wider than normal and that I'll get more natural coverage. What can I expect wrt coverage? exercise? settling? etc.

Doctor Answers 5

Breast Reconstruction

After nipple sparing mastectomy, the skin and subcutaneous tissue is very thin for good coverage of the implant. Putting the implant under the muscle and ADM is to provide good coverage for the implant.
Good coverage of the implant is better and less complications.
Based on the pictures posted, the tissue expanders you have are not in the right position and may have flipped upside down. Just follow the standard well proven technique and reposition the expander, then proceed with the implant reconstruction.
Breast reconstruction above the muscle has very thin coverage, with much more complications.
Wrapping the implant with ADM is still not proven it has that great advantage, specially in preventing capsular contracture. Nor does the ADM provide enough coverage, it is very thin. 

Baltimore Plastic Surgeon
4.2 out of 5 stars 7 reviews

Prepectoral is gaining momentum

I think your expanders are too high and too far apart and what you actually need expanded (the lower pole of your breast), isn't happening.  Your expanders can be placed in the correct position and I think your reconstruction would be a success.

A lot of articles are being published on "pre-pectoral breast reconstruction".  It's an easier recovery on the patients (just as an above the muscle augmentation is an easier recovery than a below the muscle augmentation) and easier/quicker for the plastic surgeon (even though the traditional way of below the muscle isn't that long).  It also makes a ton of money for the companies making the ADM (Alloderm in your case) that gets wrapped around the expander (typically two pieces are used on each side instead of the traditional one piece, so that's double the profit for them).  My fear is that's what is leading this trend more than anything.  Those companies have deep pockets and are able to get surgeons and even institutions to put out all sorts of studies promoting their product.  I think surgeons should spend more time studying and working on getting better at the gold standard, rather than trying to learn the next best thing.  You should be able to get a beautiful result with the traditional two stage expander-implant approach.  Just my two cents.

Hope this helps.


J. Garrett Harper, MD
Charlotte Plastic Surgeon
4.9 out of 5 stars 36 reviews

Thanks for your question.

You clearly would benefit from revision surgery and both are options, each with their own potential benefits versus potential down sides. 

These are best discussed in person during a consultation with an experienced board certified plastic surgeon. Best of luck. I am confident you can achieve an outcome with which you will be pleased. 

Ram Kalus, MD
Mount Pleasant Plastic Surgeon
4.8 out of 5 stars 23 reviews

What considerations are there for implant over muscle reconstruction after a double mastectomy?

I might offer BRAVA external expansion, weight gain than multiple lipo fat grafting surgeries to form a breast. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 173 reviews

Malpositioned tissue expanders

Hello and I'm sorry you are dealing with this following your reconstruction.  I actually do not agree that you need implants over the muscle.  Your tissue expanders are placed too high and lateral.  this can easily be fixed in another surgery.  Following a mastectomy, the overlying tissue is very thin and the added coverage of the muscle/ADM aids in achieving a more natural look.  It also reduces your rates of capsular contracture.  Fat grafting in the future can help move your cleavage a bit closer if you desire as well.  I would recommend following up with a plastic surgeon who does a lot breast reconstruction, keep looking, it doesn't not appear you have found one at this point.  

Kelly Killeen, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 6 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.