Senior Physician Speaker Series
Curated and hosted by Sam Yared, MD
Topic: Contemporary Breast Reconstruction: Eliminating Muscle Involvement, Improving Outcomesa Guest Speaker: Ryan Wermeling, MD
At the May meeting of the Senior Physicians Committee, Dr. Sam Yared, chair, introduced plastic surgeon Dr. Ryan Wermeling, who offered an in-depth look at how breast reconstruction has evolved from the era of radical mastectomies to today’ s increasingly personalized, muscle-sparing techniques.
His presentation,“ Contemporary Breast Reconstruction: Eliminating Muscle Involvement and Improving Outcomes,” highlighted the major foci in reconstructive philosophy: preserving function while improving cosmetic and psychosocial outcomes for patients recovering from breast cancer.
“ Breast reconstruction has a long history,” Dr. Wermeling explained, tracing the field back to the days of the Halsted radical mastectomy, when extensive tissue removal left patients with significant morbidity. Advances in imaging, neoadjuvant therapy and surgical precision, he said, now allow surgeons to preserve more tissue and create reconstructions that are both functional and aesthetically natural.
Reconstruction as Part of Holistic Cancer Care
Dr. Wermeling emphasized that reconstruction is no longer viewed as a secondary cosmetic procedure, but rather as an integral part of comprehensive breast cancer treatment.
“ We know that getting breast reconstruction provides a huge amount of psychosocial well-being for patients,” he said.“ Every breast cancer patient should be offered at least some sort of reconstruction.”
That patient-centered philosophy has fueled the growth of oncoplastic reconstruction, a technique combining oncologic surgery with plastic surgery principles. For patients with smaller tumors eligible for lumpectomy, oncoplastic procedures allow surgeons to rearrange remaining breast tissue to preserve shape and symmetry after radiation.
Radiation therapy, while essential for many patients undergoing breast conservation, presents a significant reconstructive challenge. Fibrosis and tissue contraction can create severe contour deformities if the surgical defect is left unsupported.
“ The fibrosis is worst in areas of no support,” Dr. Wermeling explained.“ You end up with really sometimes pretty awful defects on the breast and quite a bit of asymmetry.”
By strategically rotating and reshaping existing tissue during surgery, surgeons can prevent collapse and maintain breast projection even after radiation-induced changes occur.
The“ Fourth Dimension” of Reconstruction
One of the presentation’ s most compelling concepts was Dr. Wermeling’ s description of breast reconstruction as“ four-dimensional surgery.”
Surgeons must account not only for three-dimensional anatomy, he explained, but also for how tissue will evolve over time, particularly after radiation.
In some cases, surgeons intentionally leave one breast slightly larger immediately after surgery, anticipating future shrinkage and fibrosis caused by radiation therapy. Months later, symmetry improves as tissues settle and contract predictably.
“ The time component makes a huge difference in reconstruction,” Dr. Wermeling said.
This forward-thinking approach reflects a broader trend in modern reconstructive surgery: planning not simply for the operating room outcome, but for the patient’ s long-term quality of life.
Moving Away from Subpectoral Implants
Perhaps the most significant evolution in implant-based reconstruction is the widespread shift away from subpectoral placement, where tissue expanders and implants are placed beneath the pectoralis major muscle.
Historically, surgeons favored the muscle for coverage and vascular support. However, Dr. Wermeling argued that anatomy often makes subpectoral reconstruction less natural and more painful.“ We want to reconstruct a breast,” he said,“ not reconstruct where the pec muscle happens to be.”
In many patients, the footprint of the breast extends well below the natural position of the pectoralis muscle. Elevating the muscle to accommodate implants can create discomfort, animation deformity and unnatural implant positioning.
Instead, Dr. Wermeling now performs nearly all implant-based reconstructions using a prepectoral approach, placing the implant above the muscle and directly beneath the skin envelope. This technique elim-
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