Understanding Breast Reconstruction Options

Dr. Marisa Weiss: Hello everyone. I'm Dr. Marisa Weiss and thank you all for joining us for our special Ask Me Anything webinar based on breast reconstruction after breast surgery. To help you understand your different options, what to expect, and much more. I want to emphasize that whether to reconstruct or how to reconstruct your breasts, these are deeply personal and complex decisions and we're in a judgment-free zone. Our goal at breastcancer.org is to give you the most accurate and trusted information you need to make these big decisions for your life and the best ones. First, I want to thank our generous sponsor, the Center for Restorative Breast Surgery in New Orleans for making this program possible.

We're very grateful. We're fortunate to be joined by two brilliant plastic surgeons, Dr. Clara Lee is a board-certified microsurgeon as well as a professor of plastic and reconstruction surgery at the University of North Carolina. She's on the board of the American Board of Plastic Surgery and her research is dedicated to patient's decision-making about breast reconstruction after mastectomy. Dr. Sarosh Zafar is a double-board certified microsurgeon in plastic and reconstruction surgery as well as general surgery at the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans. Thank you both so much for being here.

I thought before we dive into the questions, I would go over a few key terms that will come up in the conversation today so that you can really participate in a knowledgeable way. You can find out more about each of these terms on breastcancer.org. But for now let's talk about, first of all, what is breast reconstruction? That's the surgery that recreates a breast with either tissue from another part of the body or with an implant. And an implant is usually made up of a silicone shell filled with either saltwater called saline or silicone gel. Flap reconstruction is the name of the procedure that uses tissue from another part of the body to recreate a breast.

And there of course there are different types of flap procedures and we'll talk about these soon. Fat grafting usually uses liposuction, which is the removal of extra fat tissue from let's say thigh, the belly area, or the buttocks. And to take that fat and transfer it into the breast area to help reshape it. Going flat describes the choice not to have reconstruction and instead to smooth out the skin of the chest after mastectomy. And sometimes we call that aesthetic flat closure. A breast form or prosthesis is what some people like to use when they go flat. They may choose to put a prosthetic or a breast form into their bra if they want to look like they have breasts.

Reconstruction done at the same time as breast cancer surgery is called immediate reconstruction. And reconstruction done after mastectomy or lumpectomy at a different time is called delayed reconstruction. Breast sensation is being able to feel things like touch, temperature on the breast skin, and of course the breast can be an erogenous zone for a lot of people and sensation can mean that for you. Necrosis is a term that refers to the breakdown of tissue that might occur when tissue is transferred and there isn't enough new blood supply to support that tissue in its new location. And lastly, options for nipples after mastectomy include getting nipple tattoos, nipple reconstruction surgery, or prosthetic nipples.

And sometimes women lose their nipple during lumpectomy and may want to look into nipple reconstruction options or whatever they can use to create symmetry in that situation. Now I'm thrilled to introduce our speakers, Dr. Clara Lee and Dr. Sarosh Zafar. And just a reminder that we will answer as many of your questions as possible. We usually can't get to all of them. I know they're so smart and they're all important and you know also that we cannot give specific medical advice that only your doctor could provide. Like Lisa said, you can send your questions using the QA feature at the bottom of your screen and we'll start the questions with ones that were submitted when people registered for this event.

I'll start with Dr. Lee. Dr. Lee, what are the risks and benefits of immediate reconstruction versus delayed reconstruction and how do you make that decision?

Dr. Clara Lee: Thank you and thanks everybody for joining us and for having me here. This is a great event. So I think there's sort of a few main differences. Some have to do with how it'll look and then some has to do with the chance of something going wrong. So immediate reconstruction generally preserves what we call the breast skin envelope. So keeping most of your breast skin and therefore it can result in a somewhat more natural shape and a shorter scar than delayed reconstruction.

So in many women, but not all, that's a benefit of immediate reconstruction. So a somewhat more natural look and shorter scar. The downside of immediate or the benefit of delayed reconstruction is it's a higher risk of something wrong happening like an infection or a healing problem with immediate reconstruction.

Dr. Marisa Weiss: And also we're always in the clinic making decisions about what is the sequence of everything. So if you're somebody who needs... You have upfront chemo and then you have surgery and you need radiation and you want to... There are all these different decisions. Sometimes we make the decision to do it right away or delaying it to a better time when things have healed up.

Dr. Clara Lee: So I can comment on that. In the past there was a strong recommendation by plastic surgeons to not have immediate reconstruction if you're going to need radiation, and a lot of times you don't know or your doctors don't know if you're going to need radiation, but some of the time they do know mostly related to whether or not you have a lymph node involved. But the traditional teaching was if a surgeon thinks that you're going to have radiation, then they would generally recommend delayed reconstruction.

There's been a general movement away from that as there's been more research showing that you can actually have reconstruction safely and then have radiation. But there are pros and cons and it gets a little complicated so definitely talk to your surgeon about that, but that's how radiation can affect that decision.

Dr. Marisa Weiss: Right, and these are such complicated decisions so different types of reconstruction interact with radiation differently. So where I practice, a lot of times they'll do a tissue reconstruction at the same time as the mastectomy, for example. Make it a little bit bigger when they know that radiation is going to be used afterwards and that tissue reconstruction can usually handle the radiation relatively well, but it may cause a little bit of shrinkage, make the volume a little bit smaller, but radiation and implant reconstruction may not get along as well.

And again, it depends on everything else you're doing and that's why we said up front these are complicated decisions that you need to make with your doctor in your unique situation. Dr. Sarosh Zafar, can you explain the difference between implants that are put in front of the muscle compared to the ones that are put behind the muscle, pre-pectoral and post-pectoral implants?

Dr. Sarosh Zafar: This is such a great question and such a common question right now. First of all, thank you everyone for listening and thank you Dr. Weiss for setting all of this up. But yes, this is a very good common question that a lot of patients have and I think that in the time span of plastic surgery over the past 30, 40 years, it has gone back and forth. What's better? To go on top of the muscle, to go behind the muscle? Even right now I think it's kind of split. I think the advantages to going behind the muscle are that your pectoralis muscle or that main muscle in your chest can help mask where your chest meets the implant and can give you a little bit more of a natural look at the top part of the breast.

One of the downsides to going behind the muscle is that then you're moving your muscle, you're operating on your muscle. It's not staying in its normal anatomy position. Going on top of the muscle can avoid obviously shifting or operating on that pectoralis major muscle. But I do think sometimes it makes the top part of the implant look a lot more obvious. One of the things that we sometimes do is to sort of soften something, excuse me. The one other issue with going behind the muscle is sometimes patients can get something called hyperanimation, which means where the top part of the skin and the nipple and areola sort of scar down onto the muscle.                 

When you use that muscle and squeeze it, it can push the implant down and out and look really unattractive. So one of the things that we sometimes do is we divide a little nerve at the top part under the muscle to help kind of soften that effect and that can kind of give you a nice happy medium between going behind the muscle but trying to avoid some of that hyperanimation. I think one of the biggest, just like we talked about immediate, delay, different types of reconstruction. This is one of those conversations you kind of have to have with your surgeon. You have to directly ask them, do you like to go above it? Do you like to go behind?

And you also should be talking to your surgeon a little bit about your lifestyle. For women who are super active in the gym all the time wearing a sports bra all the time. It may be a little bit more comfortable for you to go behind the muscle, excuse me, on top of the muscle. And so a conversation that you kind of have to go back and forth a little bit with your plastic surgeon to see what their comfort level is, how they like to address all of those different issues, whether they think if you go on top of the muscle in the future, doing a little bit of fat grafting might help mask that area where the chest meets the implant. So we're a little bit split in plastic surgery unfortunately.

Dr. Marisa Weiss: Right? I mean, as you say, the opinions differ from one era to the next, but also where people train and where you are in the country. I mean the thing about the implants that are put in front of the muscle after mastectomy, I like to think about mastectomy like you take the pillow out of the pillowcase. So you remove the breast, now you've got the pillowcase of skin left behind. And when the breast just comes out, there's a space there. You can take an implant and put it in there, whereas there isn't a natural space behind the muscle to hold the implant. So that's why the plastic surgeons need to put their hand under the muscle, lift it up a little bit, and put in a tissue expander to begin to stretch out over time, inflate the expander and stretch out the muscle so that it can approximate the skin that was left behind.                            

Now leaving a sort of very strong pillowcase that can hold this implant behind it and when there's a double pillowcase the muscle with the skin in front of it, you don't see the implant so well underneath... It's a nice sort of pad of tissue over the implant. Whereas as Dr. Zafar was saying, if you just take the pillow out the pillowcase and you put the implant right in there, even if you use a little bit of this, that to support it here and there, you can kind of see the implant under the skin and if the implant wrinkles at all, you can kind of see that.

And as she said, the animation thing, if you have the implant behind the muscle and then you're using your muscle, like you're picking up something or maybe you're shivering, then you can kind of see that muscle right over the implant look funny because it's being used as a muscle. And as we were saying, we need to know how you use your body, what your goals are because if you're a real athlete and everything, you may want to preserve your muscle in its current position because when you stretch the muscle out to become the double pillowcase kind of thing, it doesn't work quite as well as a muscle. But if you just put the implant in front of the muscle, then the muscle in its current position can do its job like it's supposed to.

And if you're into weightlifting or you've got a job at work where you're doing a twisting kind of thing or you're using your upper body, preserving it can make a difference. We've got a few more questions that we'll hit on that came in through registration and then I'm going to look at some of the questions that you're putting in now and thank you again for putting those questions in. Again, we're trying to get to as many of them as possible now. Dr. Lee, what are the different kinds of flap reconstruction to consider and are there more risks with tissue reconstruction surgery than with implant surgery?

Dr. Clara Lee: Great. I'll answer the second question first. So in general, yes, the overall risk of a complication is higher with tissue flap reconstruction than with implant-based reconstruction, and that's based on a large study that was done in 11 medical centers. Probably the biggest study of breast reconstruction after mastectomy, but it depends on what kind of risk or side effect you're talking about. So for some people they really want to avoid having an infection. Other people are like, "I can handle infection, I just really don't want it to look bad or I don't want to have a wound or something like that."

So it's important to talk to your doctor about that. The original question was, types of autologous reconstruction. So one thing to know is autologous or flap or tissue reconstruction, they're all really the same thing. The main type is using your abdominal tissue, which is generally-

Dr. Marisa Weiss: I'm sorry, can you just define autologous? It's a big word, so we want to make sure when you borrow tissue from your own body to bring it up, right?

Dr. Clara Lee: Yes. Basically it's when you move tissue from one part of your body to another and it's different from a skin graft. A skin graft, which you might hear about for someone who had a burn is where you just take skin without the blood supply and put it on the new site. Autologous reconstruction is where you take more than just the skin, generally skin and fat and the blood vessels. You move it to another site. And in the case of when we move your tissue from your tummy, we reconnect those blood vessels to the blood vessels over your chest to establish a new blood flow. So that's a major type, probably the most common type of autologous reconstruction.

Another type is using your back and you might hear that called a latissimus flap or a lat flap or a lat dorsi flap. That's different in that it's near your chest, the front of your chest comes from your back, and so it can be just kind of swung over or tunneled over. And so the blood vessels don't need to be reconnected, so it doesn't require microsurgery. It's a little bit easier to recover from and to undergo, but most of us don't have a ton of tissue on our back, so it generally is done with an implant.

Dr. Marisa Weiss: Well let me just ask you about the lat flap, the latissimus dorsi flap that you mentioned that comes from behind here and then you swing it forward. That usually involves muscle or tissue?

Dr. Clara Lee: Generally that involves transferring the whole latissimus muscle with it, but not always. So there's a version of it that's called a tap flap where it can be done without including the muscle, but not all surgeons do that. It's generally done by microsurgeons and it doesn't bring as much tissue with it.

Dr. Marisa Weiss: The reason why I ask you that is because as you consider these complicated decisions, every time you move a muscle from where it normally lives into a new place, it doesn't work as a muscle anymore. It's used as a new pillow stuffing to recreate the breast. And so that may be a non-issue for you. I have a patient who's a pediatrician who has to flip babies all the time and she had a lat flap and she couldn't do that anymore. So these are the reasons why these are very personal decisions. You want to let your doctor know how you use your body and those become considerations for all these fancy decisions that you need to make.

Dr. Clara Lee: I agree, and I think it's really important to point out that not all plastic surgeons do all of these procedures, and so you kind of want to know what that surgeon is capable of because you want to make sure that you get all of the options laid out before you that you might be a candidate for. So you might also not be a candidate if you don't have enough tummy tissue or whatever, but you don't want to be limited by just the fact that that surgeon happens to not do, for example, the DIP flap. Or there's also flaps from the buttock and from the thigh, and if a surgeon doesn't do those operations, they should at least tell you about them and say, "I don't do this, but so-and-so does or I can refer you to someone."

Dr. Marisa Weiss: And it's so important because a lot of times the breast surgeon, the surgeon is doing the mastectomy or the lumpectomy works together with a particular plastic surgeon and it's not necessarily a package deal. So as Dr. Lee is saying, plastic surgeons become so specialized. I mean the amount of training that Dr. Lee and Zafar have done in microsurgery beyond general surgery, beyond plastic surgery is amazing. These are extremely rare and precious talents that they have, but there's some breast reconstruction surgeons that only do reconstruction with implants that don't do all that fancy microsurgery and they could be great at doing implants if that's what you want.

Dr. Zafar, what type of breast reconstruction yields the fastest return to regular activity? If you've got a job that's inflexible or you've got young kids and you can't be down and out for a long time, what's the simplest type of reconstruction that can get you back into your life?

Dr. Sarosh Zafar: I think implant reconstruction, the recovery is a little bit faster usually compared to any kind of tissue-based reconstruction. So for some of our patients who have that sort of life situation, which is obviously extremely important for you to talk to your surgeon about. Sometimes we'll offer implant reconstruction and sometimes we let those patients know, "Hey, in 10 years from now, in 10 months from now, five years from now, if your life changes and you really aren't happy with implant reconstruction or you get a lot of scarring around your implants. You still sometimes can take that implant out and use some of your own tissue at a later date."

Dr. Marisa Weiss: Right, and like we were describing before when it comes to implant surgery, it might look like a shorter procedure because let's say part of the procedure is removal of the breast and maybe sampling of the lymph nodes. Then they might at that time either place the implants in front of the muscle or let's say they put tissue expanders behind, then you need to get those tissue expanders expanded over time, inflated over time. Which means a bunch of visits to the plastic surgeon and then later on you get a swap surgery where you take the expander out and you put the implant in or the expander is converted to an implant, whatever.

These are step-by-step approaches to reconstruction that are so personalized to each person and working closely with your surgeon to get the result that you want. You just need to really communicate with your plastic surgeon, let them know what you want. They were saying you want something soft to feel like breast tissue. Are you looking for a high-profile, a good cleavage there, a little trade-up? Are you looking for a permanent solution? You want to just get it done, do it now, and not have to go back for these other procedures, in which case maybe autologous where you use your own tissue to have reconstruction.

These are all these considerations that people have. We have one question that came in, Dr. Zafar, while I have you, about the people who have a lot of extra skin that they have, let's say reconstruction, but they've got like dog ears, little things are sticking out or there's extra skin here and there. What are their options to sort of tweak it to make it better over time so that they have a nice smooth shape without things sticking out on the side?

Dr. Sarosh Zafar: That's such a great question from the audience. First of all, I want to talk just for a second about why sometimes that happens. If you have some extra skin and on the day of your mastectomy or the day of your major tissue reconstruction, sometimes we can't get all of that tissue out because to get it all out, we have to carry the scar and the surgery onto the back part of your body. And when you're lying on an operating room table, it's just a logistic issue of sometimes we can't get all of that out really well. And so sometimes you will be left with a little bit of that extra skin. It's very common after the deep flap or the abdominal flap surgery to have a little bit of extra, what we call dog ear skin on the either side of the abdominal incision.

You should, if you can, have a touch-up, revision type surgery where you go back to your plastic surgeon and they can trim that skin, sometimes it involves changing your position and actually starting that surgery while you're lying on your belly, so they're working on your back a little bit to get some of that out. Same thing with the breasts. A lot of women have some extra skin on the side of the breast that carries on sort of in the bra roll area, and sometimes we have to trim that from the back as well. Sometimes we can do a little bit of liposuction to help shape that or to help bring that down as well.

And so I usually encourage women to think of Reconstruction as ideally in a perfect world, just one surgery, but in reality, our bodies, it usually takes one touch-up surgery at least after that first major surgery for women. Who have had a mastectomy and radiation and are flat and come in for a tissue bringing in skin from somewhere, some sort of tissue reconstruction surgery. Sometimes you may even need one extra tiny little touch-up surgery. And so talking to your plastic surgeon and being open about that and communicating with them, "Hey, this really bothers me. I don't like this. What can we do about it?"

And then it's sort of your plastic surgeon's responsibility to help you figure out based on your anatomy, what can be improved, what are the options for improvement, and how much of that do you want to work on?

Dr. Marisa Weiss: This might sound like a funny metaphor, but I like in reconstruction to having a new kitchen. The way your breasts were, you had them, you got used to them, they were your breasts, they're like your current kitchen, right? It's like where all the stove, the refrigerator, the sink, the silverware, the plates are, then now it's time to renovate. So you blow it all out and you build everything new and now all of a sudden everything matters. The distance between the stove, the refrigerator, the sink, the dishwasher, how deep the cupboards are, how many slots are in the silverware drawer, the handles, the soft close, the everything. And then the thing about reconstruction is that there are all these little decisions you have to make like this.

And it is your opportunity to get you back to a place where you want to be, how to represent yourself in your new life. So all these decisions are important and don't feel [inaudible 00:30:55] about or funny about asking for what you want or expressing your disappointment with something that's not what you were hoping for. And I don't know if that's helpful. Let me ask Dr. Lee about a question that came in about implants. So let's say you have implant surgery and you read the insert that says, "These only last 10, 15 years" or something like that. How long can implants live in your body? When do they need to be replaced? What if you're having no problems at all? Can they just stay there?

Dr. Clara Lee: Great. I think it's a really common misconception that they have to be replaced like tires. They don't necessarily have to be. So I generally tell patients if they're not having a problem, they don't have to be replaced. I know that the implant companies do have warranties that only last for a certain amount of time, but I would say medically, if you're not having a problem, they do not have to be replaced.

Dr. Marisa Weiss: Right. Thank you. Thank you. And there was someone who wanted to know about, Dr. Lee, while I have you, she had an allergic reaction to the tissue expander after she had mastectomies, and she wants to know if that's common or not and someone else wanted to know about... Well, we'll get to the next question. We've got a lot of questions coming in. Thank you for everyone putting their questions in.

Dr. Clara Lee: Sure. So I actually haven't read about either case reports or research on people having allergies to their either tissue expander or implant, and I certainly haven't seen it in my own practice. People definitely can have problems though with their expander or with their implant, which could be an infection or a fluid collection or even having redness of your breast that's not really an infection. It turns out to not be an infection, but the breast just stays red. So you can have reactions, but not necessarily... I'm not aware of an allergic reaction to breast implants.

Dr. Marisa Weiss: And the reality is that I've been in practice for 30 years now, a lot of times people have a number of different medical conditions. You might have psoriasis or from fibromyalgia or some kind of other type of skin condition that can get annoyed or activated when you're going through all of this stuff because it's stressful, that can definitely happen. Dr. Zafar, how do you recommend that people sequence radiation and reconstruction? Is there an ideal time that you put between the completion of radiation and the finishing up of reconstruction?

Dr. Sarosh Zafar: If you're going to have your reconstruction at the same time as your mastectomy before you have radiation, then you may need a little bit of a touch up surgery afterwards, whether that's an implant or using your own tissue. So you should wait a full three months after your radiation to do any kind of touch up surgery. If you have a mastectomy and you stay flat and it becomes radiated, you will have to have some sort of tissue, some sort of skin brought into that area to replace the skin that you're missing from the mastectomy with the radiation.

And in that case, I usually recommend three months after your radiation is complete. Now, if you have a very severe skin reaction to the radiation, you may need to wait a little bit longer, but that's a good question that you should talk to your plastic surgeon about as well.

Dr. Marisa Weiss: Right. And as a breast radiation oncologist, it's amazing how well the skin can heal, but you do need to give it time to do its magic and heal fully. If someone is going to have radiation after immediate reconstruction with implants, then sometimes it's helpful if the immediate reconstruction involves tissue expanders because then we can vary the volume on each side in order to make sure that your radiation therapy is optimal. Because if for example, you tell your plastic surgeon that you were an A cup, B cup before and now you want to take this opportunity to become a D cup, I'm just making this up as an example.

Well, you're asking the skin, the leftover skin of where the breasts had been to take on a much bigger job than they used to have to go from an A to a D. So it can stretch the skin out and the skin's not so happy to be stretched out like that, but it can handle a lot. But then to do radiation to that skin can be hard for the skin. And so we don't want to treat with radiation when the breasts are too big and the valley between the two breasts is too deep. It's like trying to land a plane between two mountains. It's hard to do. And so that's just another consideration that we consider as a team when we look over your options for reconstruction and then mastectomy and then reconstruction or right around the time of mastectomy or reconstruction after you've had lumpectomy radiation in the past.

Because I know a lot of our plastic surgeons and Dr. Lee and Dr. Zafar, they are involved with not just recreating a breast that's pleasing to you after you've had breast removal, which is mastectomy, but also after part of the breast has been removed. So those are just some things to consider. Dr. Lee, when you meet with a patient and talk about what their goals are, you've done a lot of research and shared decision-making. How deep do you get? Do you talk about nipples and sensation and size and contour and all that stuff? How do you have that conversation?

Dr. Clara Lee: I really base it on what's important to the patient. So I really focus on what their goals are and what they're prioritizing. So for some patients that's really going deep, just what you want it to look like, how big, all that, and the other side, and none of that. Other patients don't actually want to go into that level of detail. And so I try to meet patients where they are, but I would say at a minimum, a plastic surgeon should ask you, first of all, generally what's important to you? How concerned are you about the recovery?

How concerned are you about a risk of a complication and how concerned are you about how things are going to look when you're wearing clothes or when you're not wearing clothes? I go over all that with everyone and then the rest sort of depends on where they are.

Dr. Marisa Weiss: That's great. And for those of you who are listening who didn't have that conversation, make sure you write down what's important to you and communicate that to your plastic surgeon so that you're most likely to get what you want at the end of the day, knowing that this is a journey, there can be big steps and small steps and little tweaks along the way to sort of adjust things to make things more pleasing to you so that you can get the best result at the end of the day. I'm just looking down, looking at finding the questions. You guys have written great questions.

Dr. Clara Lee: Can I just add something while you're looking at that?

Dr. Marisa Weiss: Please go ahead.

Dr. Clara Lee: So I like to think of... So sometimes patients have told me that they feel like bad talking too much or asking too many questions, and I tell my patients I may be an expert in breast reconstruction, but you are the expert in you and what's important to you. And you may not know all about reconstruction, I'm going to tell you, but I don't know all about you, so I need you to tell me. So if the surgeon doesn't ask you, I encourage you to give them your expertise about yourself.

Dr. Marisa Weiss: That's great. That's great. Thank you for adding that. It's really important. And Dr. Zafar, you must see a lot of people who say, "You know what? I've heard what you have to say about reconstruction and my various options, but at this point in my life, I'm just going to go flat." Can you tell us about people who want to have a nice flat chest and it's something called aesthetic flat closure where it's nice and smooth without little pockets of skin here and there, and that's something that you do as well? Can you explain a little bit more about that?

Dr. Sarosh Zafar: Aesthetic flat closure is essentially exactly what you said, not just closing the skin at the end of the mastectomy, but being very mindful of making the contour flat, making everything look nice on the closure. Sometimes you can try as hard as you can, but you'll still get a little bit of extra skin on either side, which you may need trimmed, maybe possibly even in an office setting so that you don't necessarily have to go back under anesthesia for it. But that's the idea behind aesthetic flat closure. One of the things to know about flat closure is that our chest does not go straight up and down. Many of us think our chest goes straight and up and down. It's more rounded.

And so even though it's called flat closure, your chest is still going to sort of cave in on the sides and our chest walls, the ribs, and our breastbone or sternum are all shaped a little bit differently. And so that could vary from patient to patient. So that's sort of in a nutshell, flat closure. If you change your mind in the future, it does not mean that reconstruction is not an option for you. It's not an absolute end stop to reconstruction. And it may be that just like we talked about, some women choose to undergo implant reconstruction because of other things that are happening in their lives. Some women will choose to have flat closure because of other things that are happening in their lives.

It doesn't mean you can never have reconstruction in the future.

Dr. Marisa Weiss: Right, and it's so interesting what you say because I find I'm having this conversation all the time, which is that when people say they want to go flat, they kind of assume that their chest is kind of flat, but it could be very angled like this, like a chicken chest or it could be low in the middle and bow out on each side. That's not an uncommon chest shape, but it's also true that after you have breasts removed, if you don't have any reconstruction and then when you look down at your body, the first thing you might see is your belly. Now some people have flat bellies. Many women over life don't have flat bellies.

And as we grow older as women and as you take some of the medicines that we take against breast cancer, I'm a breast cancer survivor myself, I speak from experience. When you look down, you might see the belly might be getting a little bit bigger over time. And so as Dr. Zafar said, it may be that you made a decision up front that you didn't want anything there. You might be perfectly happy with what you have, but you still could have the option of delayed reconstruction and most insurance companies will provide support for it. It's not like your ability to have it is locked into a very narrow timeframe.

I'm not speaking for everybody because we don't know what your insurance is or if you have insurance at all, but there can be some flexibility there that your plastic surgeon and their office knows how to manage together with you. It might take a while to get there, but it can often happen. Now we are getting a lot of questions in about creating symmetry. Most people want to be even on one side to the other. So Dr. Lee, tell us about if you have mastectomy just on one side and your new breast that's been reconstructed is nice round and perky, but the other side is looking kind of sad and low, a little bit like a Christmas stocking.

How do you achieve symmetry beyond wearing a bra?

Dr. Clara Lee: I think it's really important for your reconstructive surgeon to talk to you about symmetry before you even have the reconstruction. And then when you're in this situation where you have asymmetry, there are usually a few different options including operating on the other side. In the case that you described, if you have the Christmas stocking to do a lift and probably what's called a... So a lift is called a mastopexy. Putting in an implant when you still have your breast is called an augmentation, and the combination of the two is called augmentation mastopexy.

So that's a common thing we do to match the other side, especially if the reconstructive side has an implant. Sometimes though you may want to change the reconstructive side to match the unoperated side. It depends. And then a lot of times we end up operating on both to get them to look like each other.

Dr. Marisa Weiss: Well thank you for that. Dr. Zafar, what happens when you have reconstruction and then life happens? You grow older and things start to... They don't look as good, things fall down a little bit. Or maybe if you have an implant, it starts to come down below the crease, it starts to slip down or things aren't looking like they did when you first had reconstruction. I know you see a lot of patients in that setting. Tell us about that. And if those procedures even after they were covered by insurance up front, can the redo, the tweaks, and the revisions be covered?

Dr. Sarosh Zafar: Most of the time those surgeries are covered by your insurance. There was a women's healthcare act that was passed in 1998, I believe. That said that if your insurance covers for you to have a lumpectomy or mastectomy, it will cover for your reconstruction as well as any surgery to improve your symmetry. And so thank God that law was passed and it allows women sort of access through their insurance to be able to do some revision surgery over time. It doesn't have to be within one year, it doesn't have to be within 12 weeks after your surgery. And it is just like you said, Dr. Weiss, reality as human beings, as women. Our bodies change over decades and decades and decades in life.

We cannot escape gravity, unfortunately, none of us. And that makes a huge difference. Honestly, our hormonal changes throughout life, pregnancy, breastfeeding, all of these things change our bodies so much. It's reality that some patients will need touch ups in the future. And so yes, thank God most insurance companies do cover for that sort of touch up revision of your reconstruction.

Dr. Marisa Weiss: Right. Thank you. And in terms of that wiggle room and the decisions you make over time, let's just say you had a tissue expander put in there and it's fully expanded and you're ready now to do the swap surgery, have the expanders removed, and implants put in, but you're really busy right now in your life. Kids are dealing with it. You've got a lot of stuff you're juggling, like all women are. We have the world on our shoulders, right? Is there any risk in delaying that swap surgery or delaying these steps? Can you do it when it's more convenient?

Dr. Sarosh Zafar: Usually you can. Usually, if you talk to your plastic surgeon, they can help you figure out what is a good timeline for you. In our practice, we try our best to actually go direct to implant reconstruction and avoid expanders only because a lot of the expanders have a magnet in them. And if for any reason you need an MRI, you can't really have an MRI if you have a magnet in your expander. So that's one thing to know about expanders specifically. But yes, you can delay things and similar to implants and how long can they be in, do they really need to be swapped out every certain years? In a way, if you're not having any problems, there isn't really an urgent emergency to complete your reconstruction.

I always try to encourage patients to talk to me just like Dr. Lee touched on this, and I think it's really critical for women to know. Talk to us about what's happening in your life so that we can help you figure out not only what's the right surgery for you, what's the right timing for you, but how can we help you make this work for the rest of your life and how can we help you find support? Because through some of these surgeries, you are going to need some help. You're going to need some support. If you are a mom of four young kids under the age of 10, you are going to need some help after this surgery. And it is okay.

I'm on a little bit of a tangent here, but it is okay to ask for help. It is a good thing for the people in your life who want to love and support you to help you. And so talk to us. We can help you so much better when we know a little bit about you.

Dr. Marisa Weiss: Let me ask you a question that just came in. Let's just say in your sexual life, your nipples are a major source of pleasure and you are worried that you're going to lose all that. The playground will be closed after you have breast surgery. So what can you do for somebody who got lucky that way through their life who has really erogenous nipples, but now they're worried about losing it? How do you advise them on that, Dr. Zafar.

Dr. Sarosh Zafar: My best advice is to find the best breast oncologic surgeon that you can and that is going to give you the best chance to be able to, number one, actually save your nipple and areola, and number two, save as much sensation as they possibly can. The change in sensation that happens after mastectomy happens during the mastectomy, which is sort of on the breast surgeon side. So as much research as patients do to find their reconstructive surgeon, I encourage them to do just as much research on finding a great breast surgeon as well.

Someone who maybe specializes in breast surgical oncology or general surgical oncology and is very experienced in doing mastectomies. Because the more... That perfect marriage of taking all of the breast tissue that needs to be removed, but leaving the nerves and the little bit of fat beneath your skin, that's not actually breast tissue is a pretty critical factor in saving your sensation and saving your nipples.

Dr. Marisa Weiss: Right, right. Thank you for that. Dr. Lee, can you tell us about how long the surgeries are and the recoveries are from various types of surgery? Let's let's start out with Elise, mastectomy, no reconstruction, then mastectomy placement tissue expander or an implant. If you could rattle through that like you do with your patients, please.

Dr. Clara Lee: Sure. I'll just say it varies a lot by surgeon. So the mastectomy varies by surgeon and the reconstruction is varied by surgeon, but a mastectomy not including the lymph node part generally takes one to two hours per side and then a little bit more for the lymph node. Doing a tissue expander or implant, adding that adds about an hour per side. Again, plus, minus. Tissue reconstruction with your tummy, which is a DIEP or TRAM, a free flap. That also varies quite a bit. Probably at Dr. Zafar's Center which specializes in those kinds of procedures, it's four hours.

 But I would say most surgeons, it's about an eight-hour surgery for two. It's not quite twice as long, but probably more 12 to 14 hours. And then a latissimus flap is about four or five hours. And then with each of these, the hospital stay is longer. So with an implant it doesn't add anything to the hospital stay on top of the mastectomy. For a DIEP flap from your abdomen, the hospital stay should be about three days, sometimes less, sometimes more. And for a latissimus flap, one or two days.

Dr. Marisa Weiss: Thank you so much. This is what I tell people, and this is just my general rule of thumb, which is that for every hour under anesthesia translates into about a week of recovery. So that's just a rough measure. So let's say your surgery takes three hours. You're going to be done and out for three weeks at least afterwards. I'm talking about down and out. You're going to be stiff and sore beyond that. If you have a 10-hour operation where you had double mastectomies and you had tissue from the belly transferred up to make new breasts, 10 hours, that's 10 weeks. You've got to plan for 10 weeks of getting help from other people to do the lifting and the various things or being out of work or making an arrangement.

And there's nothing... Of course this is very rough as a measure, but as Dr. Lee said, it's so specific. So it varies a lot depending on you, your health. Do you have diabetes? Are you a smoker? Have you had complications from surgery? Are you heavy? Are you carrying a lot of extra weight around or were you fit before the surgery? Were you running marathons before this procedure? Because you'll probably have a better chance of running out once you're done. I'm not exact because these procedures, even the best of us have to take time out and then make arrangements to transition back into the life that we want.

One thing I would definitely say to people who are listening is that these procedures require a lot of effort during the time of healing. You want to make sure that you get the best result possible and the best result happens when you heal properly from the procedure that you have without complications. I know the three of us, Dr. Zafar, Dr. Lee, and I have patients who are training for the Boston Marathon or some big marathon and they don't really believe us when we say, "You got to lay low after this procedure because this is a big operation." You need to take the time to heal. That's really important. Don't mess up a good thing and push yourself too far, too fast.

And then you see that person overexert themselves, decide they're going to move out and lift all the furniture and they're going to do that marathon, and then they come crawling back with a little bit of a bleed here, or they maybe got an infection or something didn't work out like it should. And we as doctors can be really firm, and I am one of those doctors that's really firm about the shared commitment we all have to make to the best result possible and the best result is always the greatest benefit and the least side effects. And as Dr. Lee and Dr. Zafar said, it's a partnership. We can do the best we can, but we have to work together so that at the end of the day you have the best result possible.

And it may mean sacrificing certain things like not running the marathon that year or letting your toddler crawl up on your lap rather than always picking the baby up and putting him on your lap. There are modifications that we need to use, but it's so important that we work together and communicate. Dr. Zafar, I have a question. We have a lot of great questions coming in and there are questions about changing your mind later. Let's say you have lumpectomy radiation and over time you've gained weight or lost weight and the breast that was treated... I'm a breast radiation oncologist.

Basically the breast that was treated doesn't gain and lose weight in the same way as the other side. So now let's say you're 10, 15 years out and the breasts are in different places, you're not happy, you got a new... You're now determined to get on Match.com and meet a partner and you want things to look good. Is there any time limit to coming back to meet up with a plastic surgeon saying, "Hey, can you make my situation better? I'm not happy with what I have."

Dr. Sarosh Zafar: There's no real time limit. Honestly. Some of the different things that we do are operating on the other. Sometimes to lift it or to reduce it. We can sometimes do a lift or a reduction on the side where you've had the lumpectomy and radiation. If you have a very severe... If just for some reason your body, the way that it's scarred, the way the radiation handled it or the ratio of tissue that was removed was a pretty large part of your breast compared to what's left over, you may have a pretty big deformity there.

Sometimes we actually remove the rest of the breast tissue that's called a completion mastectomy and sort start from scratch, excuse me, start from scratch and then we'll bring in some tissue either from your abdomen, your back, your upper kind of buttocks area to reconstruct the breast as whole. To kind of make it look whole again and to make it look more uniform. And then of course, whatever sort of symmetry surgery you need on the other side to make that as symmetric as we can.

Dr. Marisa Weiss: Well great. We only have a few minutes left, so I thought maybe we should talk about the icing on the cake, the nipples and the areola complex. So let's say someone had a reconstruction, they have new perky breast mounds and they don't have nipples and they're looking for nipples. The way I think about it is if someone walks into a room and they have no eyes and eyebrows, the face looks funny. And if someone walks in with two mounds with no nipples, it doesn't really look like a breast until those... It depends on your perception and how you see things.

The nipples, the projection and the areola, the dark circle of color around it does make it look like a breast. So what would you say, Dr. Lee, about how do you approach the nipple conversation with your patients in terms of surgery, tattooing, or the combination?

Dr. Clara Lee: I think a few things. One, if you can, try to see a breast surgeon who knows how to do nipple sparing and talk to them about that. You may not be a candidate, but if you are, that would be great to have that option. And then obviously if they're gone, the main options are doing a small skin flap to fold around the skin to make a little mound, and then that's often tattooed or just tattooing, which looks like the image of a nipple, but it's flat. And then I generally talk to my patients about what they prefer. And some patients are so glad to no longer have nipples and not have to wear a bra. But others, like you said, it just doesn't look right and then everywhere in between. So I think it should really be your choice.

Dr. Marisa Weiss: Thank you. It is so personal, isn't it? And the placement of the nipples, because you don't want one nipple looking straight up and then one nipple looking down. Dr. Zafar, what's your approach to nipple reconstruction and the timing for that?

Dr. Sarosh Zafar: Exactly what Dr. Lee just said. Some women really love, like she said, the fact that they don't have to worry about going braless and their nipples are not showing. And some women really just want the surgical nipple reconstruction. Timing-wise, the nipple and the areola are kind of the finishing final touch on the breast reconstruction usually. And so you want to be several months out from what you feel like is your final revision. And once you get to that point, then that's when you add the nipple and areola. If you add it on too soon before you have a symmetry surgery or... If you add it on too soon, then it can become asymmetric and then that will drive you crazy.

Dr. Marisa Weiss: Yes, it will. And also the skin has to heal because if you wanted to have three-dimensional 3D tattooing, that's a procedure that involves putting little needles in and out of the skin. The skin has to be ready for that. Well, I want to thank you both so much for being here. We have to leave it there for questions, and thank you so much to every one of you who shared your questions. We have a plan and we're going to figure out our final plan about how to address some of those great questions later. But before we go, I want to remind everyone that we have a comprehensive collection of information for you on Breastcancer.org, so that you can learn even more about options for breast reconstruction. For a few examples, there's the surgical images photo gallery.

We have some podcasts, articles, videos, and even checklists like What to Ask Your Plastic Surgeon Before Surgery. And you can join our community online and talk with other people who have been in your shoes, who've been trying to make these decisions also. We can send you links to all of these resources.

Thank you so much for joining. I hope today's webinar has been helpful to you and that we can continue to support you through our community, the information we provide and all of our programming, and we want to wish you the best. Please take care.

Q: Do you have info about the goldilocks procedure of mastectomy? 

A from Jamie DePolo: Yes, see this page. 

Q: What does the recovery look like for a double diep flap reconstruction? 

A from Jamie DePolo: This page may help.

Q: I would like to know more about hybrid reconstruction. 

A from Jamie DePolo: See this page.

Q: I am likely going to have breast reconstruction utilizing my upper thighs as my stomach is not viable due to other surgeries. How is the recovery for this surgery 

A from Jamie DePolo: Check out this page.

Q: Are there standards around doing breast reconstruction for overweight women?  I was turned away surgically due to my BMI and have not found many resources to help me understand why. 

A From Jamie DePolo, Breastcancer.org: I'm sorry you were turned away. Check out this research news story, especially the What this means for you section, where Dr. DellaCroce explains that women of any size can have reconstruction. 

Q: I would like to inquire about the aesthetic flat closure option.  This is almost never discussed as an option. A from Jamie DePolo: We have a lot of info here.

Q: Is there an age limit to having breast cancer reconstruction? A from Jamie DePolo: As long as you don't have any other health issues that might affect your ability to have surgery, no there isn't an age limit.

Q: What type of follow-up screening (MRIs, CT etc) are required if you want to get implants? I'm considering a preventative double mastectomy (I only medically need one removed) just to avoid all the screeningss if I kept one natural breast. A from Jamie DePolo: The info on this page will be helpful. 

Q: I am interested in options for reconstruction revision, following total mastectomy with implants. I am very unhappy with how my breasts look now, 6 months after my implant exchange, due to a large amount of rippling. A from Jamie DePolo: You may want to watch this video: and view this page.

Q: I had BC 13 years ago with a lumpectomy, chemo and radiation. It was triple negative. I’ve since found out I have BRCA1. Soon after I met with a surgeon about having a mastectomy and recon. At that time she said I couldn’t get implants because my skin was compromised by the radiation. Has that changed?  I feel like it would be much easier healing to have implants vs skin removal and taking stomach skin and fat.  Any resources would be appreciated. 

A from Jamie DePolo: You may want to meet with a different plastic surgeon to discuss your options.

Q: Is re-sensation surgery successful? 

A from Jamie DePolo: Check out this discussion about that topic. 

Q: Is it true that implant silicone can cause cancer or other issues on our bodies?

A from Jamie DePolo: We have a lot of information about breast implant associated illness on our website about that topic.

Q: I have had great PT and treatment post bilateral mastectomy and breast-reconstruction, and I highly recommend PT for others. However, I have had a hard time finding appropriate bra/support/ or other items to wear that are comfortable around my chest, under the armpits, etc. Any recommendation would be greatly appreciated. 

A from Jamie DePolo: You may want to visit a mastectomy fitter at a specialty bra shop to ask about special bras. I've found them to be very knowledgeable.

Q: Once you develop capsular contracture, is it reversible without treatment? Does it most likely occur again if you have a revision surgery? If it’s not too advanced, is it dangerous not to get surgery to fix it? 

A from Jamie DePolo: Here’s more information about capsular contracture.

Q: I wasn’t told about or given any options for reconstruction other than implant reconstruction.  Can I have the flap procedure or fat grafting in the future? A from Jamie DePolo: In most, but not all, cases this is possible. See this video and this page. 

Q: I had a bilateral mastectomy with autologous reconstruction 4 weeks ago.  How long does it take for the reconstruction to reveal final results?  I may be interested in liposuction transfer since I don't want an implant. 

A from Jamie DePolo: It depends on the type of flap recon you had. In most cases, doctors say up to 12 weeks for double reconstruction.

Q: I was wondering if during the DIEP flap reconstruction, if the side boobs will be removed or disappear. 

A from Jamie DePolo: If you're concerned about side boobs or "dog ears" as many surgeons call them, make sure to talk to your surgeon ahead of time.

Q: Do you still have to get mammograms after mastectomy and reconstruction? 

A from Jamie DePolo: That depends on your unique situation. It's best to ask your doctor if you need mammograms or other types of screening. See this page.

Q: I'm so disappointed in the outcome and my limited options after radiotherapy.  I'm struggling emotionally with this huge decision and feel trapped with how my body looks.

A from Jamie DePolo: I'm so sorry to hear that. I would suggest talking to a different surgeon/getting a second opinion. See this video and this article.

Q: Is it better to have 1 or 2 breasts removed to prevent breast cancer recurrence and for cosmetic symmetry? 

A from Jamie DePolo: That is a very personal decision and depends on your unique situation and level of recurrence risk. It's best to talk to your doctor about what would make you most comfortable.

Q: Please explain contracture with implants. What can be done if this has occurred?  I feel like I have a suction cup on my hand chest.  My implant has raised up on my chest. 

A from Jamie DePolo: There is a lot of info on this page.

Q: Is it an easier to do implant compared to DIEP flap in terms of time and procedure? 

A from Jamie DePolo: Dr. Zafar mentioned that implant reconstruction usually has a faster recovery and shorter surgery time.

Q: My tissue expander has moved around a bit every so often. Will this also happen with the permanent implant? 

A from Jamie DePolo: Implants can move, but just because the tissue expander moved doesn't mean the implant will. It's best to talk to your surgeon about this.

Q: Are nipples removed during the goldilocks surgery? 

A from Jamie DePolo: I believe that depends on the type of mastectomy you're having. See this page.

Q: Thinking of having a DIEP procedure. Input on this process?

A from Jamie DePolo: This page has a lot of good info to help you with your decision.

Q: I’m a candidate for a superior gluteal artery perforator (SGAP) reconstruction.  What is the typical recovery timeline for that procedure? What about risks? 

A from Jamie DePolo: This page has a lot of good info.

Q: If choosing non-reconstruction, should we also work with a plastic surgeon to get Aesthetic flat closure procedure?

 A from Jamie DePolo: Yes, definitely talk to a surgeon about aesthetic flat closure.

Q: Is there a risk of cancer by doing implants? I am trying to keep the cancer away and not have the possibility of it coming back because of the choice of implants. 

A from Jamie DePolo: Textured implants are associated with a higher risk of a rare type of lymphoma, but not a higher risk of recurrence.

Q: My surgeon oncologist only mentioned I get a lumpectomy, he didn’t mention reconstruction at all. Shouldn’t reconstruction be discussed for lumpectomies? 

A from Jamie DePolo: Yes, you can definitely have reconstruction after lumpectomy.

Q: I am stage IV with a gene mutation that increases my risk of a secondary breast cancer. Are doctors still able and willing to do a bilateral mastectomy or is this not recommended as I will always be on treatment? 

A from Jamie DePolo: That depends very much on your treatments and where the cancer has metastasized to. It's best to talk to your doctors or get a second opinion if you don't get the answers you want.

Q: I had a bilateral mastectomy and reconstruction after radiotherapy but the teardrop silicone implant turned so I removed everything and decided to be flat, then I tried with liposuction fat but it was absorbed after a short time, now I am flat with fat cysts, what can I do without putting implants?

A from Jamie DePolo: You could talk to a plastic surgeon about some type of flap reconstruction.

Q: I think I asked this in registration but can you talk about the swap surgery? Does the saline filled expander get drained before it is removed? What is recovery like? 

A from Jamie DePolo: This article explains what to expect. 

Q: What is the best option for Black/African/Carribean skin that is prone to keloid scarring? What are the best post-surgery meds to help with scarring? 

A from Jamie DePolo: This video has info about that topic.

Q: When is an expander used versus an implant? 

A from Jamie DePolo: This page also has a lot of info about implants.

Q: Do you have any articles about how your skin changes after radiation in regards to post-mastectomy and reconstruction? 

A from Jamie DePolo: Thanks for joining. See this page for more about radiation side effects.

Q: What questions should we ask the Radiation Oncologist to ensure that my breast isn’t mangled during treatment, and that the end result after radiation is a breast that looks as best as possible? 

A from Jamie DePolo: I would tell the radiation oncologist just that. That you're very concerned about how your breast will look after treatment.

Q: I am of slim build and not a lot of body fat, what would be the best reconstructive option? 

A from Jamie DePolo: That's best discussed with a plastic surgeon. We have info on reconstruction types on this page.

Q: Once you develop capsular contracture, is it reversible without treatment? Does it most likely occur again if you have a revision surgery? If it’s not too advanced, is it dangerous not to get a surgery to fix it? 

A from Jamie DePolo: This page has a lot of good info.

Q: How long can it take to recover from a DIEP Flap reconstruction?

A from Jamie DePolo: See this page for more about DIEP flap reconstruction.

Q: I opted for implants, however my plastic surgeon did not ask me about below or above muscle.  We did not talk about the type of implant (gumminess) or what the outcome should look like, natural or more augmented.  We talked about size and the doctor went way above the desired size.  She was willing to do an implant exchange and I gave her a cc amount not to go below. She went way below and I hate the outcome. I'm uneven and wrinkly. The implants seem uneven (which can happen).  Do I have any other options at this point? 

A from Jamie DePolo: You may want to get a second opinion. This video has a lot of good info: and this page too. 

Q: Is it common to be diagnosed with 2 tumours in the same breast?  And is it common to then have surgery to remove the tumours and have two lumpectomies at the same time?  Or is it better to have  the breast removed? 

A from Jamie DePolo: Many people have more than one tumor in the same breast. As far as surgery type, that is up to you and what you're most comfortable with, as well as your unique situation.

Q: Hello, Can you suggest something to put on my scar after double mastectomy? I have some widening/ thickness of the scar. I am using vitamin E oil and bio oil. Is there something I should be using other than the oil? 

A from Jamie DePolo: See this page about scar tissue. 

Q: What are the common causes for skin necrosis? If surgeries are performed too soon before full healing has completed, can that cause skin necrosis? 

A from Jamie DePolo: See this page for information.

Q: During the DIEP surgery,  and the tissue is taken from the abdomen, is it the same as having a tummy tuck at the same time? 

A from Jamie DePolo: It's similar. See this article. 

Q: I had bilateral mastectomy followed by radiation. My radiated breast is hard and high. I have had two failed revisions to the non radiated breast and are now looking at a fourth revision to try to match the radiated side. Both revisions have failed (spit stitches that basically unzipped everything that was revised)and the non radiated breast is still very low and mismatched. Can this be fixed or do I give up and live with completely mismatched breasts? 

A from Jamie DePolo: You may want to meet with different surgeons and get second or third opinions. See this article and this one.

Q: I don’t know what to ask my plastic surgeon at my upcoming appointment. Do you have a list of questions that you have been asked? 

A from Jamie DePolo: Yes, we have this checklist that will help you prepare. 

Q: For a person with one breast, that is large, and sagging with age, can it be lifted to match the prosthetic breast? 

A from Jamie DePolo: Yes, that can be done.

Q: Why would reconstruction be needed after a lumpectomy?  I'm trying to figure out which option is best for me and I'm just so lost on which option is better for me. 

A from Jamie DePolo: This article explains more about reconstruction after lumpectomy.

Q: What are options for nipple reconstruction? Is it just tattoos? 

A from Jamie DePolo: This article explains options to consider.

Q: My implants are 12 years old under the muscle and are silicone implants. When is it time to replace implants in general? Is it best for implants to be placed under the muscle or over?

A from Dr. Lee: There is no real need to replace implants if you are not having a problem with them. However, since you have silicone implants, you should have imaging (ultrasound or MRI) regularly to make sure that they have not developed a leak. The FDA recommends having imaging 5-6 years after they were placed, and then every 2-3 years thereafter.

Re: placement under (subpec) or over the muscle (prepec), there are pros and cons to each.

• Subpec generally results in a smoother contour or slope along the upper part of the reconstructed breast, where the implant meets the chest wall. It generally also shows less rippling because there is an additional layer of tissue between the skin and implant. However, it may be harder to recover from. It results in "animation" in which the implant moves when you move your upper body and flex the pectoralis muscle.

• Prepec avoids the issue of animation and may be easier to recover from. It may also have a more natural appearance to the lower part of the reconstructed breast. However, the upper part may have less of a smooth slope, and the implant's rippling is generally more visible. Many surgeons always do fat grafting after the prepec approach to improve the appearance. You need to have some excess fat for that.