How do you and your patients come up with the plan on which procedure to do and which one’s more common implants are more common and plants are more common okay because at the end of the day almost everyone is a candidate for a breast implant type of reconstruction and the flap has to have either enough donor site tissue and then a patient who’s willing to go through the extended recovery of the flap surgery so the flap surgery we always say is sort of an investment in the beginning in the long term you don’t have to worry so much because you don’t have an implant you don’t have to have revisions and things like that 10-15 years down the line which is common with a breast implant but the recovery is certainly longer on the first operation for implant operations they tend to be quicker but they have a higher overall complication rate and they have a higher risk of loss of the reconstruction at least temporarily because of that do you have a percentage of women that maybe opt not to have reconstructive surgery for whatever reasons and maybe decide in the future or just not to do it at all that’s an excellent question and it’s a pendulum because if you look at breast reconstruction maybe 10-15 years ago not everyone was offered reconstruction now pretty much everyone in America has offered breast reconstruction but it’s not always the right thing for everybody older patients sicker patients it’s you know patients that have an aggressive cancer that needs urgent treatment those patients often benefit by no reconstruction or delayed reconstruction and it’s an important part of the conversation to say this is a personal decision that needs to be made and there is not necessarily a wrong answer with saying I don’t want to go on with a reconstruction right now you