Choosing Between Over or Under the Muscle

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I was recently chatting with a friend about a few complaints I have with my current implants and they asked me if I had chosen to have my implants placed over or under the muscle. Lets get one thing straight - I didn’t know that I had an option. When I went in to have my double mastectomy I knew practically nothing. I knew my surgeon would be removing my breasts to reduce my lifetime risk of breast cancer but that’s about ALL I knew tbh. We are given SO much info and it’s so overwhelming. So my doctor did what he thought was best or what he was best at. Fast forward to two years later - I now know wayyyyyy more info, what questions to ask, and that us Breasties have a lottttt of options. I hope that if you are navigating your options, this information is empowering for you, and not overwhelming. If you are wondering if you should be going with under or over the muscle, I recently sat down with Dr. Anne Peled to get us some answers.

Dr. Anne Peled

Dr. Anne Peled

First of all, Anne is a total badass. She is a board-certified plastic surgeon in San Francisco who specializes in breast, reconstructive, and cosmetic surgery. She is uniquely trained as both a plastic surgeon and a breast cancer surgeon. In addition to her clinical practice, she serves as the Co-Director of the Sutter Health California Pacific Medical Center Breast Cancer Center of Excellence. OH… and she is a young breast cancer survivor herself. Aka she is a Breastie and is AMAZING!!

If you don’t feel like reading the entire interview (you should read it all - ITS GOOD!!) then to sum it all up - in general Anne advises us Breasties to go Over The Muscle!!

BUT LET’S START WITH THE BASICS… WHAT IS DIRECT TO IMPLANT VS HAVING EXPANDERS?

DTI (direct-to-implant) allows women to receive implants during the mastectomy procedure and skips over the expander stage. The typical UTM implant-based reconstruction uses a two-stage approach. First, a tissue expander is placed at the time of the mastectomy. After expanding to the desired size, the patient is returned to the operating room for their exchange surgery, where they replace the tissue expander for the final breast implant. With OTM implants, either two-staged with expanders or DTI, the implant is placed above/over the muscle. Anne has some exciting news for women having prophylactic surgeries - the majority of them can go DTI. Anne says, “a lot of doctors think that you have to do expanders first because then you can get the size that you want and see how they will look. I use a 3D program that can show you what the different sizes will look like and I prefer to go the DTI route as often as I can.”

WHAT IS OTM VS UTM?

For both types of surgeries, the mastectomies are essentially performed the same way and then the reconstruction starts.  For UTM, a new space is created underneath the pec major muscle and the tissue expander or implant is placed underneath. The pec major covers about half/two-thirds of the expander or implant and then typically the rest of it is either covered by lifting up another muscle along the side of your chest (serratus) or by sewing a piece of Alloderm* to the edge of the pec major muscle (which gets completely disconnected from your chest along the bottom of your breast) and to the chest.  For OTM, all the chest muscles are left completely intact and then the expander or implant is placed on top of the chest in the space where the breast was and then a piece of Alloderm is placed over the expander or implant and sewn to the chest wall muscles in different spots to make a pocket for it. According to Anne, “both surgeries require drains for an average of 1 to 2 weeks afterwards and usually one night in the hospital, though some women with OTM reconstruction go home the same day since it's less painful.”  Both types of reconstruction can be done with nipple-sparing or skin-sparing mastectomies, or done as delayed reconstructions or revision reconstructions.

SO WHAT IS ALLODERM?

Let’s back up a bit - for anyone wondering what Alloderm is - it is made from cadaver skin. AlloDerm is derived from donated (cadaveric) human skin. It is FDA approved and is used in many different types of reconstructive surgeries. Before being packaged for use, the Alloderm undergoes a multi-step process that removes all the cells. Alloderm essentially acts as a scaffold and over time, the patient’s own cells grow into it. Doctors use Alloderm because it stabilizes the implant in position, allows for complete implant coverage, and once incorporated by the body, resists infection as well as the patient’s “natural” tissue. HOW CRAZY IS THAT?! It still freaks me out a bit but most of the breasties I know who have used Alloderm with their reconstruction have THE BEST results. So it is definitely something I am considering…

WHAT IF YOU WANT TO GO BIGGER THAN YOUR CURRENT SIZE?

Anne says it depends on what size you want to go, but in general you can go up one full cup size and still choose to go DTI.

DOES EITHER OPTION HURT WORSE THAN THE OTHER IN TERMS OF RECOVERY?

Although some women do still have some early chest wall pain with OTM since the Alloderm gets sewn to the chest, it goes away quickly and the recovery is much faster.  Stretching the muscle with UTM reconstruction, especially with expanders, can potentially hurt for a long time after surgery and some women actually have chronic chest pain afterwards. I personally struggled with tightness for a long time after my surgery and still struggle with minor chest pain and back pain.

DOES EITHER OPTION LEAD TO MORE SENSATION?

“No one has studied this yet so we don’t know - but sensation is probably mostly related to the way the mastectomy is done and baseline breast nerve anatomy, type of reconstruction likely doesn’t impact it too much,” says Anne.

However, she says that she is able to use a technology called Resensation that can help restore our sensation during or after our mastectomies. It’s a new technique where nerves from the chest are reconnected with nerve grafts to nerves in the mastectomy skin. I was shook when Anne told me this, because she said that even though I have already had my mastectomy and reconstruction, I can STILL use Resensation if I decide to switch from UTM to OTM and she can use this technology to help me regain sensation… HOW AMAZING IS THAT?!

To learn more about Resensation, you can watch this video of me explaining it HERE.

WHICH OPTION IS BETTER FOR ATHLETIC WOMEN?

If you are eager to get back to working out, you should look into OTM!

“Definitely OTM because from the base line you aren’t disrupting your pec muscle,” says Anne. “ OTM is ideal from both a functional standpoint and an aesthetic standpoint. If you are an athlete or workout often, UTM is not ideal because the stronger and more developed our muscles are, the worse our hyper animation will be.”

This makes SO much sense!!! No wonder I look like The Rock when I work out lol

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WHICH OPTION HAS LESS RESTRICTIONS WHEN IT COMES TO WORKING OUT?

According to Anne, most surgeons are more likely to allow women to exercise quicker with OTM because you haven’t disrupted your pec in any way. There aren’t many restrictions, YES YOU CAN DO PUSHUPS, because you haven’t disrupted the muscle. Anne’s typical Protocol: by four weeks you can go back to almost everything expect planks and pushups and you can get back to those after six weeks. Check out her blog post with more info here.

WHICH OPTION LOOKS MORE NATURAL?

All bodies are different and the results vary Breastie to Breastie, but Anne thinks that women with OTM recon end up having more natural and softer looking results.

WHO IS THE IDEAL CANDIDATE FOR OTM?

Everyone! One of the biggest lessons I have learned over the past two years is that doctors tend to recommend what THEY are best at not what is necessarily best for YOU.

Anne explains, “not all plastic surgeons are trained in OTM,” since it is a newer technology. She encourages us to, “go to people who are up on the latest, safest, new and innovative care. This drives everyone to be better. So when you are doing your research, seek out doctors who are up on the latest innovations because that will require all doctors to catch up and enable them to do what is best for their patients.”

I LOVE THAT! ^^

WHAT IS THE BEST OPTION FOR WOMEN WITH TRIPLE NEGATIVE CANCER?

The most important thing for women with triple negative breast cancer is getting them the best treatment. What you choose for your surgery should come second and is independent of your diagnosis.

IS IT BETTER TO HAVE RADIATION BEFORE OR AFTER RECONSTRUCTION?

This should be discussed with your doctor as it is specific to the individual. But in general it is hard to stretch the skin once you have had radiation which is why most women who require radiation have atleast an expander placed before they begin radiation to maintain skin space.

DOES EITHER OPTION MEAN FEWER MRI’S?

Unless there is a concern with recurrence/new cancer or implant rupture based on exam, MRIs aren't typically ordered for screening once women have had bilateral mastectomies.  This is the same for either option.

DO UTM IMPLANTS MAKE FOR EASIER SCREENINGS?

“When surgeons first started doing OTM reconstruction, this was a concern,” Anne explains. “But, so far this hasn't been seen to be an issue, especially since recurrences/new cancers are often felt in the mastectomy skin/along the side of the reconstruction when they happen.  Also, when DIEP/flap surgery is done, the flaps are also placed OTM, and studies with many years of follow-up for women who have had flap surgery has not shown this to be less safe from a breast cancer perspective.”

DOES THE STRETCHING/CUTTING OF THE MUSCLE HAVE AN IMPACT ON YOUR BACK AND SHOULDER POSTURE?

Yes, which is a big reason why Anne doesn’t typically perform UTM reconstruction. “The muscles of your trunk (front and back) are all connected in differen ways,” explains Anne. “Stretching muscles in your chest – switching from UTM to OTM will help with posture and pain since the muscles/fascia of your trunk are all connected to each other, it makes sense to think that cutting or stretching muscles of the front and sides of your chest could impact the muscles of your back and shoulders.  Many women also have chronic tightness or spasm of their stretched muscles, which can definitely impact posture and cause back or neck or chest pain.”

This is something that I am currently struggling with. My shoulders are constantly hunched over and I have pain in my chest and back, which is a major reason I want to switch from UTM to OTM.

WHAT IS THE RECOVERY LIKE SWITCHING FROM OTM TO UTM?

“The pain should be minimal, since you aren’t putting any pressure on the muscle. However, you will need to have drains again for a week to a week in a half.”

NOT the DRAINS… anything BUT the drains….

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When switching from UTM to OTM , you take the muscle off of the mastectomy skin flap and sew it back to were it was before the mastectomy. The implant is then placed on top. So there is no tight muscle/stretched feeling. No tightness. 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 later.  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.

One of our Breasties, Shirley Mendes (@mendes4325), switched from UTM to OTM and she explains:

“The recovery wasn’t anything near the mastectomy. I did have to have drains again for two weeks. I guess when you switch you can have drainage and then it can slow down and then in the second week pick up again. Those two weeks were tough, the drains really suck. They are just so effing sore. Also my surgeon doesn’t let you shower until they come out due to infection. Once the drains came out things improved quickly. It was about a month when I started feeling back to normal. My results are night and day better! My surgeon put in a larger implant because my projection wasn’t there before. I feel like they look more natural and more apart of me, it that makes sense.”

WHAT ARE THE POTENTIAL DOWNSIDES TO SWITCHING TO OVER THE MUSCLE?

When implants are placed over the muscle, they can sometimes be more visible or easier to see 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.

DOES SWITCHING FROM UTM TO OTM FIX CHEST WALL HYPER ANIMATION?

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 Alloderm.  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:

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.

IS ALLODERM / CADAVER THE ONLY OPTION?

“You wont do as well if you don’t use alloderm,” Anne says. “You have higher rates of capsular contracture and issues of hardening your implants if you do not incorporate Alloderm. OTM works so well because of Alloderm. It sounds crazy to put cadaver skin in your body but its really just a matrix because they take out ALL of the cells.”

It STILL freaks me out but TRYING to get over it….

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IS SWITCHING FROM UTM TO OTM COVERED BY INSURANCE?

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

IF YOU ARE THINKING ABOUT HAVING A REVISION SURGERY…

Anne believe that we all deserve to look in the mirror every day without the constant reminder of cancer or our genetic mutations. She hopes that we feel empowered by our revision surgeries, with the permission to look as healthy and cancer-free as we feel. I highly recommend that you read Anne’s blog post about her personal decision to undergo a revision. You can read that here. But here is a snippet:

“While my first surgery was overwhelming because of all of the cancer unknowns, like whether or not my lymph nodes were involved and if I’d need chemotherapy, this time feels “elective”, which brings a new set of emotions with it. When I reassure my patients that their initial or revision breast reconstruction surgery will be covered by insurance because it’s not their choice to have breast cancer or a gene putting them at high risk for breast cancer, I like to think it gives them permission to truly accept the surgery as reconstructive, and not cosmetic (which it of course isn’t). And even though I completely believe this for myself as well, somehow it still leaves me wondering if going through surgery again is something I really “need” to do. I’m cancer-free and honestly have a pretty fantastic result thanks to my amazing surgical team, which makes me question if I should just ignore the subtle divots and asymmetries left from my cancer treatment instead of going through another surgery? Is it worth it to put myself and my family through another recovery when I’m truly grateful every day to feel so healthy and am completely settled back into all of my pre-cancer exercise and work routines?”


This information should be used as a tool to better understand what YOUR options are and to feel empowered when you talk to your doctor to ask the right questions, understand the procedures and the benefits and drawbacks. At the end of the day, it is YOUR body and it is YOUR choice. Knowledge is power and you should always feel empowered to take charge of your health and ask for what YOU want.

To discuss if this surgery may be helpful for you, please call Dr. Peled at 415-923-3011 or e-mail her at info@apeledmd.com.



if you loved this interview and want to see more like this in the future, please leave a comment below, share this with your friends, and let me know what topic i should cover next!! love you all so much!! xo