Anne Peled Plastic Surgery

The blog of Dr. Anne Peled, board-certified plastic surgeon. Dr. Peled discusses breast reconstruction and breast cancer surgery topics and operates in the San Francisco area.

21st Century Breast Reconstruction: Less Invasive, Better Outcomes

I recently saw a woman in my office who had been diagnosed with breast cancer over 30 years ago, at age 37.  At that time, she had undergone a simple mastectomy without reconstruction, a major lymph node dissection, and chemotherapy for what sounded like a small, very treatable, Stage I cancer.   Since that time, as would be expected, her non-cancer breast had gotten larger and dropped over time, and as a result of the major asymmetry between the two sides of her chest, she had mostly been wearing hoodies or loose-fitted patterned sweaters for years to try to hide her chest.  She had also developed neck and shoulder pain as a result of the lopsided-ness of her chest and found that even trying to wear a mastectomy bra and prosthesis wouldn’t fix her asymmetry in clothes and her pain.  She had been living like this for 30 years, without knowing her asymmetry could be significantly improved with an insurance-covered reconstructive surgery.

I was so struck by how things had changed over 30 years between her treatment and mine after my recent breast cancer diagnosis at the same age she had been.  With a small, Stage I cancer, women like me have the option of avoiding major lymph node surgery and can instead have just a few lymph nodes removed, saving them from potential complications such as long-term arm weakness or swelling. With the development of genomic tumor testing, women can get information tailored specifically to them that can help them make informed decisions as to whether or not they would benefit from invasive treatments such as chemotherapy.

And finally, on the reconstructive side, there have been so many advances that truly improve how women look, feel, and recover after breast cancer surgery.  Most women now have the less invasive option of breast-conserving surgery, which can be combined with a number of different reconstructive techniques (“oncoplastic surgery”) that avoid future divots at the lumpectomy sites and can in some cases lift or reduce the breasts in a way that makes them look even better than before surgery.   For women having mastectomies, they can now often have nipple-sparing mastectomies, giving them the psychological and aesthetic benefit of keeping the external appearance of their breasts.  When combined with less invasive types of reconstruction such as over-the-muscle (“pre-pectoral”) implant reconstruction, women can be back to their normal lives in a matter of weeks with natural looking breasts.

For all of us who treat women with breast cancer, or have had breast cancer ourselves, we’re so fortunate to benefit from the advances of the past 30 years and to eagerly await the advances coming in the next 30.

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Pre-Pectoral Breast Reconstruction

Switching to pre-pectoral (“over-the-muscle”) breast reconstruction: how to fix chest wall hyperanimation

Up until the last few years, most women who had implant reconstruction after mastectomy typically had their implants placed under their chest wall muscles.  Now, however, we know that women can get great reconstruction results with implants placed over the chest wall and covered with a soft tissue supportive matrix such as AllodermÒ.  The benefits of this approach are more natural looking results, less chest wall pain, and most importantly, complete elimination of “hyperanimation deformity”, which is the appearance of the muscle and implant moving up with chest movement that many women with implants under the muscle experience.

For women who have hyperanimation after implant reconstruction below the muscle, here are some answers to help you think about how best to fix it:

How does switching to pre-pectoral reconstruction help with hyperanimation?

Switching the implant from under- to over-the-muscle involves freeing up the chest wall muscle from the overlying breast skin and sewing it back in place to its normal position on the chest wall.  By doing this, when the chest wall contracts, it is no longer visible because the implant and the soft tissue supportive matrix are now sitting underneath the breast skin and in front of the chest wall muscle. Studies show that 100% of women who have their implant switched to the over-the-muscle position have their hyperanimation fixed.

What is the recovery like after the surgery?

Because the new implants are placed over the muscle, women have little discomfort from the surgery and can go home the same day.  Typically drains are placed during the surgery and removed around 10 days to two weeks.  Once the drains are out, women are free to go back to most of their normal activities and can be back to full exercising by four weeks after surgery.

Is this surgery covered by insurance?

Because this is a reconstructive surgery, insurance companies are required to cover the procedure.

What are the potential downsides to switching to over-the-muscle reconstruction?

When implants are placed over the muscle, they can sometimes be more visible or easier to feel in the upper part of the breast, depending on how much soft tissue coverage women have in that area following their mastectomy.  A good way of addressing this is to do fat grafting at the time of the surgery, where fat is transferred from one part of the body (usually the abdomen or thighs) and then placed into the breast to help camouflage the edge of the implant.

To discuss if this surgery may be helpful for you, please call Dr. Peled at 415-923-3011 or e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

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