Pros and cons of over vs. under the muscle breast reconstruction.This week, James E. Craigie, MD, of The Center for Natural Breast Reconstruction answers your question.Question:I had a Dbl. Mastectomy 6 months ago. The expanders were placed & then removed 2 months later, (necrosis) I've lost confidence in the original plastic surgeon & went for 2 consults with new Dr's. One wants to do above the muscle (as did the original Doctor.). The other says that it needs to be under the muscle. In my research, I've found the pros & cons to both, but I've also read that in above the muscle technique there has to be enough breast tissue. So my question is that since I had mastectomy could I have enough tissue for above the muscle? Is there a better choice? One Dr suggested that above the muscle is the lazy way to do it.. is that the case? Thank you.Answer:  Thank you for your question. I’m sorry to hear you have had problems with your breast reconstruction. There is no one procedure or technique that is best for every patient or for every plastic surgeon. If you had necrosis after your mastectomy then any technique used for breast reconstruction could be very difficult. Breast reconstruction with implants is always difficult when there is necrosis and putting the expander under the muscle may not help in any way. Normally the breast is above the chest muscle. When breast reconstruction with implants is performed with the expander or implant below the muscle then there is always distortion or unnatural movement of the breast when the chest muscles contract. For many patients this is a significant problem. The problem is avoidable when the implant is in a more natural position. We call this approach prepectoral breast reconstruction. If someone has a mastectomy they should have no breast tissue to cover an implant/expander. That is one of the downsides to breast reconstruction with implants. It is a problem regardless of whether the implant is above or below the chest muscle. The best breast reconstruction results with implants are when the implant is not below the muscle, but in the normal pre pectoral position. I strongly disagree with the “lazy” excuse. Breast reconstruction with expanders /implants in front of the muscle is much more work for the plastic surgeon compared to below the chest muscle. It also requires specialized expertise and judgement. You should also be aware that if you have already had problems with your implant breast reconstruction then your best option for a permanent natural result may not be implants at all. Your own fatty tissue may be your best option. Please let me know if you would like more information about natural muscle sparing breast reconstruction without expander/implants. I hope that I answered your question. Please let me know!Have a question about breast reconstruction or post-surgical you’d like answered from our surgical team? Just ask(opens in a new tab)!