Prepectoral versus Subpectoral Reconstruction
There are now several ways to do implant based reconstructions. I try to match the correct reconstruction technique to each patient and discussion is key.
Prepectoral reconstruction is a relatively new innovation in implant reconstruction. The breast tissue is removed and the implant is put on top of the muscle in a capsule or hammock made of mesh rather than under muscle. This reconstruction has the improvement of no animation of the muscle during exercise, no loss of muscle strength or discomfort but has the down side of reduced padding over the implant which means it is more visible under the skin. This can cause “rippling”; the ripples or folds in the implant can be seen through the skin in certain positions. Fat grafting can be used later on after the reconstruction to camouflage the rippling and give a layer of padding over the implant. I think of it as removing fat from somewhere you don’t want it and putting it somewhere that it is useful. I now do almost all of my breast reconstructions this way as I find they are less painful with a quicker recovery and that the muscle is not affected for everyday function.
This is how my reconstructions used to be done. The implant was placed inside a part muscle/ part mesh pocket. This gave more padding in the cleavage area over the implant but had the disadvantage of the muscle contracting whenever it was used. This could be uncomfortable and unsightly as the muscle scrunched up. I still occasionally use this technique in very thin women especially if they are not very active as it will give less rippling. I also use this in women who have already had an augmentation procedure as the muscle is already stretched out and they have fewer problems with rippling and discomfort.
Conversion from subpectoral to prepectoral reconstruction
I occasionally convert subpectoral reconstructions to prepectoral reconstructions on patients who have had their reconstructions done years ago and who find the subpectoral reconstructions uncomfortable or the muscle twitching annoying.