New Approach to Breast Reconstruction May Reduce Pain and Weakness for Some

American medicine is commercialed, and you can't trust journals and newspapers. Is it a wonder then that people consult Google and carry amulets?

As a plastic surgeon performing breast reconstruction, I think it's important that readers understand 1) this is a promotional article, not a scientific medical journal article and 2) what being a paid consultant promoting this procedure means. Over the years I've performed both the above the muscle and partial sub-muscular procedures. Above the muscle isn't the best thing since sliced bread. Being above the muscle puts the entire implant a few mm's below the skin. This can sometimes predispose to unnatural results since the implant is more visible, can feel less natural to the touch, and I believe has overall more risks of fluid accumulation and infections. The appearance are better with tear drop textured implants, but these implants have their own risk of potential secondary cancer, ALCL, a rare lymphoma. This is missing in the article, as is the reporting of potential increased revisions surgeries needed with fat grafting. NYT should have made more transparent a doctor's disclosures. Free info published online by Pro Publica, reported 13.4 million paid to docs to promote this very specific graft product. NYT, why not disclose the consultant rec'd $249K in 2016 from this company? The Times should be sensitive to know that breast cancer patients are reading this article thinking this is the latest and greatest. It's certainly new and can have some benefits in some patients...but it's not necessarily the given first choice.

First of all, thank you for publishing a story regarding pre-pectoral implant placement. This alternative technique, in my opinion, could be the next big thing in reconstructive- and aesthetic breast surgery. As a clinician, with extensive research experience in plastic surgery and fundamental cellular biology (PhD), this article unfortunately seems biased and does not show the whole picture. Yes, usage of a mesh in pre-pectoral implant placement seems paramount: Unfortunately, only the usage of ADM is mentioned. With Dr. Sbitany’s role as a consultant to an ADM manufacturer, I noticed the sole mentioning of ADM as mesh option. Recent literature contradicts his choice: ADMs are more prone for infection then resorbable meshes, due to the nature of the material itself. Use of ADM is dropping significantly in EU (or are banned) in favour of other meshes. Moreover, alternative meshes are 50% of an ADM price, have similar aesthetic outcome and are 100% halal. Just to be clear: I do not propagate permanent meshes, because of the simple fact that NOTHING can be anchored permanently in the body: the tissue eventually determines breast pocket strength. Implant revision surgery is most likely more complicated. In my opinion fully resorbable meshes (like the Novus Scientific TIGR-matrix or CR Bard phasix) are superior, and should be discussed as valid alternatives in the outpatient clinic. Let this be a -unbiased- and open discussion. J.C.N. Willemsen M.D. PhD. Rotterdam-Holland

the major complaint of upper pole wrinkling is artfully neglected here, and one of the reasons submuscular implants are used. There is a need for liposuction and injection of fat necessary in at least half of the prepec reconstructions. This requires a second or third procedure, not truly just one. Insurance will not pay doctors adequately for that procedure either. So, the material costs twice as much, not paid for, and then the upper pole wrinkling is deforming, and requires MORE surgery, not adequately compensated. COMPLETE disclosure please.COSMETIC augmentations still done under muscle! Wonder why?

First of all, thank you for publishing a story regarding pre-pectoral implant placement. This alternative technique, in my opinion, could be the next big thing in reconstructive- and aesthetic breast surgery. As a clinician, with extensive research experience in plastic surgery and fundamental cellular biology, this article unfortunately seems biased and does not show the whole picture. Yes, usage of a mesh in pre-pectoral implant placement seems paramount: Unfortunately, only the usage of ADM is mentioned. With Dr. Sbitany’s as a consultant to an ADM manufacturer, I noticed the sole mentioning of ADM, without discussing alternatives. Recent literature contradicts his choice: ADMs are more prone for infection then resorbable meshes, due to the nature of the material itself (rough pig collagen). Use of ADM is dropping significantly in Europe (or are banned) in favor of other meshes. Moreover, alternative meshes are 50% of an ADM price, result in comparable aesthetic outcome and are 100% halal. Just to be clear: I do not propagate permanent meshes, because of the simple fact that NOTHING can be anchored permanently in the body: the tissue eventually determines breast pocket strength. Implant revision surgery is most likely more complicated. In my opinion fully resorbable meshes (like TIGR-matrix) are superior, and should be discussed as valid alternatives in the outpatient clinic. Let this be a -unbiased- and open discussion. J.C.N. Willemsen M.D. PhD. Rotterdam-Holland

As a 15 year breast cancer research and patient advocate, a 4 time breast cancer survivor and a person who has had 2 autologous reconstructions (using your own tissue for reconstruction) who has been very happy with my choice both immediately and long term, my advice is to be your own advocate, take ample time to do your research (Breast cancer is usually not an emergency!), listen to own inner voice, select a surgeon who has done lots of the exact type of surgery you end up choosing and speak with other women who have been through it. Living Beyond Breast Cancer (lbbc.org) offers free buddy match ups. And if you are deciding or have chosen autologous reconstruction, the private Facebook group DiepCJourney is an excellent resource.

This is an interesting article. The author, however, should also include the option for a woman choosing not to have any reconstruction at all! There are many of us who have made this choice. We have fewer complications, avoid multiple surgeries and get back to our lives much faster. The choice NOT to have any reconstruction needs to be examined and discussed by doctors and surgeons on an equal basis with any reconstruction options.

I dearly wish that doctors would routinely tell women that for many staying flat is the best option. When women receive a breast cancer diagnosis they are most likely in shock and may not have the time or the mental bandwidth to do their research. Even if they are told about different types of reconstruction they are being given only a subset of their options. The flat life is not for everyone, but then again neither is reconstruction.

I could be a poster child for this option. I had a prepectoral prophylactic skin and nipple sparring double mastectomy earlier this year (I have a BRCA mutation) and recovery was shockingly easy--no real pain, ever, and almost complete arm movement within a couple of days of surgery (e.g. I could dress, bathe and feed myself with no issues-under the muscle people typically are debilitated for days/weeks.) After doing my research, I specifically asked my plastic surgeon for this. He said he would need to make the call about whether he would go above or below the pec when I was on the table, when he had a better sense of the blood flow to the area and the skin quality--fortunately, he was able to do it! I had tissue expanders inserted at tge time of the mastectomy--I asked for a new type, called AirXpanders, which lets you inflate the pocket with CO2, instead of saline, from the comfort of your home--and looked "normal" within 3 weeks of the mastectomy. Final implants put in 12 weeks later, and that was a breeze, too. Now I look completely normal--with my clothes on and off. Needing this surgery, due to cancer or a mutation, absolutely stinks. Having a less painful option is a reAl game changer.

I'm 35, had to have a mastectomy 9 months ago. I opted out of reconstruction and am flat. What ghastly options women have... All of these "pink" organizations make it seem like women get breast cancer and then wear a pink shirt and life goes on. Even a simple mastectomy and removal of lymph nodes is an ordeal with consequences. Due to my age doctors handed me lumpectomy brochures but what's the point of having a mashed up mutilated breast and undergoing radiation? "well we can use a flap from your stomach to create a breast." Uh.... what? Why ruin other parts of my body to create mounds on my chest? Why shove foreign objects in there? Reconstructed breasts will never be breasts. They simply fill a shirt so you can pretend to the outside world that nothing happened. Even the "good" pictures look like Frankenstein to me and are an insult to natural breasts. As a low income person, I have no idea what the future holds and I'll likely be locked into poverty so the idea of having future problems/sickness from implants/needing to replace them along with a natural gut reaction aversion to them -- I said no. My recovery from surgery has been much easier than my mom's and my aunts'. In fact, my mom's reconstructed breasts are one reason I said no..... when I hug her I am now met with a hard wall of fake-breast between us. That's not what I want to experience when I hug people.

In 2014 I had my 4th recurrence of BC in the same breast. Previous occurrences were treated with lumpectomy and the 3rd with following radiation. The 4th occurrence was the final straw and I had a complete mastectomy. At the time my surgeon highly recommended reconstruction and arranged for the plastic surgery consult. I opted not to do reconstruction because I was put off by the tram flap procedure, and I wanted to be sure I would be able to "feel" any subsequent cancer if it came back on my chest wall. I don't regret the decision (much), and my prothesis works just fine to maintain my shape in clothes. I don't enjoy facing my altered chest everyday when I step out of the shower and get dressed. Honestly, I miss the symmetry of having two breasts, but I'm glad to be alive and over chemo and back on one year follow ups. As for my chest wall, I know every nook and cranny and any cancer that dares to spring up again will be discovered asap!

I had a mastectomy when I was in my mid-40s. I had an implant under the muscle, because I didn't want to be always worrying about whether or not my clothes necklines showed any cleavage. The expansion pre-implant was a bit of a nuisance, but not really painful. Now, 30 years later, I am wondering if the implant has moved up a bit, but it may just be that the other breast has sagged more (lol.) I had been concerned that having the implant might make that side less strong when rowing, or climbing, etc. but my surgeon assured me that it shouldn't make a difference, and he was right! I have been able to lead as active a life as I would have without the cancer. Perhaps I have been just lucky, but I am happy that my choice of chemo and implant has worked out very well.

Also chiming in to share that I had a positive experience with double mastectomy reconstruction with tissue expanders implants 5 years ago and continue to be happy with the results. I also had nipple reconstruction and "tattoo." So everyone's experience is unique.

When I had a single mastectomy in 1999, in my 40s, the choices I was given for reconstruction were a)taking an abdominal muscle and moving it to my chest to create a sling for an implant, or b)taking a back muscle and moving it to my chest for the same purpose. Both were anathema to me. Why ruin a part of my body that worked perfectly well to create a makeshift breast?? I opted for no reconstruction and have been using a breast prosthesis ever since. I miss going bra-less sometimes, or wearing lower-cut necklines, or having matching breasts in a bathing suit. But I'm very glad I made the decision I did, and have had no physical problems at all in the years since.

My first BC was treated in 1982 with lumpectomy, axillary dissection and radiation. 10 years ago, a new BC developed inside the lumpectomy scar. Result then was a double mastectomy with extra chemo as a repeat patient. Stretching for implants was painful. At one point, the radiated side burst open a few hours after an expansion, needing prompt surgery to remove & replace the expander + remove saline from the non-radiated side to even up the size, which was significantly smaller than the real breasts had been. Eventually, these implants will need removal & I'll then go flat. The radiated tissue is too fragile for another implantation. Depending on my movements, the diagonal chest wall muscle on top of the non-radiated side distorts the shape of the implant. Mine are the teardrop shaped silicon "jelly" type. If one's tissues are strong enough to support them, the pre-pectoral reconstruction sounds like a big improvement.

I am just over 50 and had double mastectomy with pre-pectoral reconstruction in July of 2018. It has been an incredibly positive experience so far, and I wanted to write and share this point of view. My surgeons are at MD Anderson, and truly world class, so that is important as well. Further, I was able to do a one-and-done, nipple sparing procedure, and apart from some minor wrinkling on one side, I look better than before. While I care more about how I feel, I am glad to feel proud of my body. I also feel very good, not the same -- I have limited sensation -- but no pain. I was lucky to have large flaps, and low grade cancer that did not require treatment beyond surgery. I am an avid athlete and wanted to preserve my life, first, and my ability to play sports, second. Situations are very different, but in mine, the pre-pectoral surgery has been amazing.

I have given this a lot of thought. If I develop a new cancer or a reoccurrence, I am going flat. I really cannot have an implant because of the radiation, and am not going through that flap reconstruction. If I develop cancer on the other side, I am going flat. Doctors are not really forthcoming about the significant risks of all of these reconstruction surgeries. Each type of surgery comes with significant risks and a very good chance that you will be back in the operating room because of complications. No thank you.

I applaud the NY Times for illuminating some of the more cutting edge techniques we are using in breast reconstruction. Like most topics, however, the reality is more nuanced than a short article can convey. Whether women have less long-term chronic pain with this technique remains to be proven. It seems intuitive that not having a device under the muscle would be more comfortable; however, there are myriad causes of discomfort after a mastectomy, including nerve injury, loss of sensation and proprioception, the development of scar tissue on the chest wall, and the effects of additional treatment modalities, including radiation. There is one significant factual error in the article. Direct to implant or one stage reconstruction can be performed in with implants behind or in front of the muscle. So patients who undergo pre-pectoral reconstruction are probably not any less likely to require a second operation. Indeed, these patients may require revisions more often to thicken the tissue around the implant to prevent a shrink wrapped or wrinkled appearance. As this article suggests, reconstruction has improved immeasurably over the past 30 years. Yet while I have devoted my career to breast surgery, I still tell patients that the reconstruction is a poor substitute for a breast. It can lead to complications, require additional surgery and cost, and may need long-term maintenance. That said, reconstruction can help many women reclaim some of the normalcy they have lost.

I have found that doctors have not been very forthcoming about the options available to women for reconstruction. It was only through friends and internet support groups that I found Dr. Jyoti Arya, one of the few plastic surgeons on the West Coast who was doing this above-the-muscle reconstruction, which was pioneered on the east coast. The operation takes true partnership of a general surgeon for removal of cancer and plastic surgeon on reconstruction. It helps to have a duo that has worked together often and effectively. That said, the approach offers great simplicity, limits or eliminates the need for more surgery and general anesthesia, and offers excellent results.

I'm a recent breast cancer survivor and opted for the "goldilocks" reconstruction after double mastectomy. I now have small breasts that were formed from fat grafted from legs. I have no implants. I was planning on going flat, but when this option was presented, it seemed like sensible middle ground.

At the time I was told I had cancer, I had already been scheduled with a surgeon and a plastic surgeon. When I asked not to have reconstruction, I was dismissed: "No, you won't look right without it." (I was 66). I asked if I could have small enough implants not to need extra surgeries- so I ended up with implants that were literally up at my collar bones. The plastic surgeon, knowing he had screwed up, started talking about putting in extenders and larger implants- even though he knew I didn't want any. He simply didn't care how I felt. I went to the other plastic surgeon in town and had them taken out. I have never ever regretted not being reconstructed.

The website to Flat and Fabulous https://www.flatandfabulous.org empowers those of us who want to minimize medical procedures. Going flat would raise breast cancer awareness more than any pink ribbon. The fashion industry would do well to design elegance for those of us who remain asymmetrical.

Though it's so difficult at a stressful time, please educate yourself. Though you may like your local doctor, physicians are not always candid about all reconstruction options - only the ones that they perform. Please take the time to research which doctors within a reasonable distance are doing which procedures - you cannot count on plastic surgeons to recommend things that they, themselves, don't do. It's wrong, but it's nearly always the case. If you have an academic medical center nearby, that's always a great place to start as their physicians are typically the most well informed. Unfortunately, each woman needs to be her own best advocate.

I was diagnosed more than 26 years ago, at age 34. The treatment options were well explained to me, and because of my age, I chose the most aggressive option of mastectomy plus chemo. It was awful, all of it, and I still suffer, myriad ways. The reconstruction options were not well explained, though one pretty hateful explanation was that the implant would be like stuffing a chicken breast. Yuk. I put up with that implant for more than 20 years, until it had crept up nearly to my shoulder! That took it out of the numb zone and created active pain. I had it replaced with an under the skin and I think non-biological mesh pocket implant, and that’s been fine. My only complaint is that I think my surgeon used the guaranteed insurance payment to stretch the process into 3 surgeries instead of 2. Three years later, my chronic fatigue syndrome is still worse than it was before 3 long sessions with anesthesia.

I am a recent breast cancer survivor who opted for direct implant after double mastectomy. The implants were placed under my muscles and it was nothing but pain and torture for nearly five months. I had them removed after two infections. I agree that surgeons encourage women to go for reconstruction and gloss over the complications. I wish I had gone initially gone flat. Please stop the insanity.

Another possibility is to flat and avoid these risks.

There's probably no good answer for this, but a big part of the problem is there just seems to be no way to know beforehand, what each of these reconstruction options is really going to be like for the person who has to live with them. Even the surgeon doesn't really know what your new body is going to feel like, or how your particular body is going to respond to all the many changes. And there are many, many changes, even if you look fairly "normal" on the outside. That makes it tough to make informed decisions. Plus surgeons tend to encourage their pet technique over other options. Not to mention that when you are dealing with the terrifying immediacy of breast cancer treatment, the idea that you can investigate and reason through the reconstruction process is really kind of an unreasonable expectation, anyway. Everything is just a stunned blur.

I was wondering why they put the implants under the pectoral muscles and wondering if this would cause trouble.

I have never regretted Not getting reconstruction, despite heavy pressure to do so from $ surgeons. I was repulsed by the medieval “expander” used under the chest muscle. Really? That’s the best they got? No thanks. Complications happen more often than we are led to believe (1/3). Mastectomies hurt a long time. Women are not told how numb they will be, forever. Lymph edema catches up with you. I understand how people can get wound up in the self-image issue, but why have a lifetime of pain and complications when there’s enough of that in store for aging post-cancer people. And why risk having to go through “revision surgery” to repair or remove them? The body never bounces all the way back from surgery.

All of this discussion about reconstruction makes me thankful for two things: (1) the studies that showed that recurrence and mortality outcomes were similar for lumpectomy/radiation and mastectomy; and (2) my lumpectomy could be done with minimal disfiguration to my breast. This made it very easy to opt for lumpectomy/radiation as a treatment plan. (As a side note, I would have had to have chemotherapy, regardless of surgery choice). That said, I'm pleased to see that clinicians are actively working to increase success rates and outcomes for reconstruction, as I realize that not all women are in the position to choose surgical options.

As one of the early adopters of this 4-5 years ago, I would caution people being overly enthusiastic. Except for patient's with the thickest mastectomy flaps, long term coverage is a problem, as is the tendency of the implant to settle and stretch the skin more. The cost of the materials used (made from cadaver skin) adds $20,000-30,000 cost in materials per case which is a tremendous issue. I have largely quit doing this technique as the results are generally worse aesthetically and require more revisions compared to partial sub muscular techniques (like used on breast augmentation). The issue of "animation deformity" is dramatically overstated in my obeservation