American Society of Plastic Surgeons
For Medical Professionals
5 years ago

Prepectoral reconstruction and screening

I have stage 2 Invasive ductal carcinoma. I've had a double mastectomy. My plastic surgeon has recommended prepectoral reconstruction as I'm 53, active, 5'8, 120 lbs, and want to be a 34" B cup. My oncologist is concerned that the only way to do cancer screening is an MRI (will insurance cover this?). What are your thoughts on prepectoral reconstruction and cancer screening?

Procedure: Breast Augmentation
Location: Bainbridge Island, WA

Replies 4

Steven Wallach
ASPS Surgeon
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I personally don’t get all the hype about prefectural implants. In my opinion, it’s like trying to rediscover the wheel. Subglafukar breast implants initially always were less painful( the muscle was not cut, or stretched from an implant)., however long term rippling and higher incidence of capsular contracture were noted in this plane. Now you have a breast with even less soft tissue coverage, and will have a higher incidence of rippling and visibility. We’ve know this for years with subglandular breast augmentation. Yes you can add fat grafting, but in my opinion it is likely going to be less aesthetic than a submuscular one

Debra Johnson
ASPS Surgeon

Because you are very lean, I would be concerned that you would have visible rippling of the implants in the upper/medial breast, since you likely have thin skin covering an implant. Submuscular placement would provide more camouflage, but you would notice the muscle pulling on the overlying skin and flattening the implant when you tighten your pec muscle. I would consider a highly cohesive gel implant which ripples less, or a baffled saline implant well filled. You could also consider gluteal flaps as an autologous recon option.

Recurrent cancer could appear either right under the breast skin or on top of the pec muscle. With an autologous recon or prepectoral implant you can only monitor the breast skin. With subpectoral implants the muscle is right under the skin, so it can be readily monitored as well. Recurrences usually appear within the first 5 years, but only affect 2-4% of patients.

Daniel Allan

Plastic surgeons learned many years ago that that women who are having an augmentation mammoplasty obtain a better result if the implant is placed under the pectoralis muscle, which provides a thick layer of well-vascularized tissue over the implant. Obviously, a woman who has had a mastectomy has even less tissue to cover the implant than a small-breasted woman having an augmentation. Products such as

AlloDerm have been/are used by some surgeons to augment the tissue coverage of the implant, but they can bring their own problems. I don't know how much skin you have, how thick the surgeon left the flaps, etc., so I cannot comment on whether you would need tissue expansion, but if there is any doubt, you should do it, and take more time with the expansion process than is currently fashionable. Your insurance should cover the MRI because it is related to your cancer diagnosis, but you you will have to ask them.

Nelson Castillo

Thank you for sharing your excellent question. Prepectoral reconstruction offers certain benefits for patients in terms of recovery time and pain but must be weighed agains the potential cons including visible rippling and wrinkling of the implant. Best to talk to your plastic surgeon at length, or seek out second opinions for the best advice.


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