One-Step Prepectoral Breast Reconstruction With Dermal Matrix–Covered Implant Compared to Submuscular Implantation: Functional and Cost Evaluation

Establishing an equipoise: Does the use of acellular dermal matrices in pre-pectoral implant-based breast reconstruction improve outcomes?

INTRODUCTION

Breast cancer is the most common malignancy among women in the United Kingdom. Surgical management commonly comprises mastectomy and reconstruction, of which implant-based breast reconstruction (IBBR) is the most prevalent. Acellular dermal matrices (ADM) are widely used in pre-pectoral IBBR; however, there is limited high-quality evidence supporting their efficacy. This study aimed to establish an equipoise via an expert consensus survey.

METHODS

An online survey was designed with a steering group of experts. Questions covered participant information, opinions regarding surgical outcomes with ADM use in pre-pectoral IBBR and opinions regarding the available scientific evidence on the topic. The survey was advertised via national and international professional organisations. Quantitative and qualitative analyses were performed.

RESULTS

Thirty-two participants from the UK, Italy and Australia completed the survey. Key findings of this study included disagreement among participants regarding the surgical outcomes associated with ADM use. Participants who believed that ADM reduced the risk of short-term complications and implant failure/explantation comprised a minority (21.9%). Participants who felt that ADM use improved cosmetic outcomes and reduced long-term complications were a relative majority at 43.8% and 40.6%, respectively. Furthermore, 56.3% of the participants felt that there was scarce scientific evidence on the topic.

CONCLUSIONS

This study provides insights from international surgeons, establishing a lack of consensus on surgical outcomes, efficacy and evidence-base supporting the use of ADMs in pre-pectoral IBBR. Given this clinical equipoise, alongside the growing burden of breast cancer associated morbidity and need for reconstruction, the implications of this study are that large-scale, prospective, randomised-controlled data are needed to establish whether ADM use in pre-pectoral breast reconstruction improves the outcomes.

Immediate Breast Reconstruction in Skin-Reducing Mastectomy with Prepectoral Polyuretane (Pu) Implant Covered with an Autologous Dermo-Adipose Flap

BACKGROUND

The aim of this study was to present our new technique of immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, in skin-reducing mastectomy both for risk-reducing (prophylactic mastectomy) and therapeutic cases.

METHODS

We performed a single-center, retrospective review of 21 patients (mean age 47 years), undergone skin-reducing mastectomy and immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, un the period January 2018-June 2021. All procedures were performed by the same surgeon.

RESULTS

A total of 36 skin-reducing mastectomies (6 curative, 15 prophylactic) with one-stage prepectoral PU foam-coated implant and autologous dermo-adipose flap reconstruction were performed. All postoperative complications were collected. Quality of life (QoL) and satisfaction with reconstruction were evaluated through the BREAST-Q questionnaire, administered preoperatively and at 12 months after surgery. Independent Student's t tests were used to compare means of continuous variables and Chi-square test was used for ordinal variables. A p-value ≤0.05 was considered statistically significant. Uni- and multiple linear regression analyses were used to confirm all results. Out of 21 patients, we observed one small wound dehiscence and one partial Nipple-Areola Complex (NAC) necrosis. All cases of minor complications were managed conservatively and did not affect the quality of the final outcome. No implant loss was observed. No significant severe capsular contracture (grade III or IV) was detected at follow-up. Overall satisfaction with breasts, psychosocial, physical and sexual well-being all significantly increased, analyzing BRAST-Q data. Statistical analysis showed a significant influence of diabetes on the risk of complications.

CONCLUSIONS

Our experience suggests that the procedure described is effective, feasible and cost-effective. It is easier to perform compared to similar and more demanding procedure, reduces operative time, and minimizes complications related to manipulation of the pectoralis major muscle, while also contributing to the containment of costs. Moreover, it appears to be oncologically safe, provides good esthetic results with low postoperative complication rate and leads to high level of patients' satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous coverage for direct-to-implant pre-pectoral reconstruction in large and ptotic breasts: a new technique

Direct-to-implant (DTI) breast reconstruction after skin reducing mastectomy in large and ptotic breast is characterized by a high rate of complication. The Dermal Sling is commonly used to give extra coverage to the lower pole of the mammary implant to lower the risk of implant exposure in case of wound dehiscence at the T-junction. The aim of the paper is to detail an original technique that combines an inferior dermal sling with pectoral and serratus fascial flaps, to create a pre-pectoral pouch. We retrospectively review the clinical data of the patients who underwent Type IV/V mastectomy and DTI breast reconstruction with the described technique. Minor and major post operative complications were analyzed. Patient satisfaction and aesthetic outcomes were evaluated at one year of follow-up through Breast-Q and Validated Aesthetic Scale. Ten patients (fourteen breasts) were included in the study. Skin and/or NAC necrosis occurred in three breasts. One patient underwent implant removal due to periprosthetic infection. At one of follow-up no capsular contracture nor migration of the implant were clinically detected in all patients. One patient had a visible rippling at the upper quadrants of the new breast. Good patient satisfaction and aesthetic outcomes were reported. The association of fascial flaps and dermal sling is a viable option for breast reconstruction in patients with large and ptotic breasts. Along with providing an autologous coverage for the implant, it allows to maintain a good projection, maximize symmetrization in case of concomitant contralateral reduction mammoplasty and avoid any implant displacement.

Prepectoral Breast Reconstruction with Prosthesis and Acellular Dermal Matrix: A New Technique of ADM Implantation and Fixation

Background

Direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique and linked to better overall results. The introduction of new surgical techniques has prompted us to develop an acellular dermal matrix fixation technique that reduces the rate of complications and implant loss.

Methods

We retrospectively analyzed data from patients who underwent DTI prepectoral breast reconstruction with two different techniques of acellular dermal matrix fixation to the chest wall. Descriptive statistics were reported using frequencies and percentages for categorical variables, and means and SDs for continuous variables. Pearson chi-square test was used to compare differences in categorical variables. Univariable and multivariable logistic regression models were fitted to investigate the predictors of complications.

Results

From October 2019 to March 2023, 90 DTI breast reconstructions were performed, 43 using the standard technique and 47 using the new technique. The new technique demonstrated a significant reduction of major complications (P = 0.010), namely seroma (13.9% versus 2.3%), skin necrosis (9.3% versus 2.3%), implant loss (7% versus 0%), wound dehiscence (9.3% versus 0%), and infection (4.7% versus 0%). Compared with the standard technique, the new one reduced the risk of complications by 76% (OR 0.24; 95% confidence interval 0.09-0.68; P = 0.007) and 73% (aOR 0.27; 95% confidence interval 0.08-0.92; P = 0.037), at univariable and multivariable regression models. No other significant predictor of complications was identified.

Conclusions

The procedure performed with the proposed modality proved to be advantageous. Careful fixation of the prosthetic implant and the placement of two drains, were the keys to a drastic reduction in complications.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Tissue Expander-based Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center.

Methods

All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days.

Results

There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, P < 0.001), be discharged by day 1 (96.5% versus 70.2%, P < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, P < 0.001). Seroma rates (17.4% versus 3.5%, P < 0.001) and hematoma incidence (4.5% versus 0%, P = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (β=-60.7, P < 0.001) and a shorter inpatient duration by 0.4 days (β =-0.4, P < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (β=-30.9, P = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, P = 0.009).

Conclusions

ERAS protocols significantly reduce opioid use and hospital stay after TEBR.

Surgical and Patient-Reported Outcomes After Mastectomy and Implant-Based Prepectoral Reconstruction Using TIGR® Synthetic Mesh

Background Single-stage direct-to-implant (DTI) breast reconstruction after mastectomy has gained popularity over the last decade, thanks to the wide use of biological matrices and synthetic meshes. Despite their high cost, there is no evidence of superior outcome from the biological matrices compared to the synthetic meshes. In this study, we aimed to evaluate our experience with TIGR, a synthetic, long-term absorbable mesh, in mastectomy and immediate breast reconstruction (MIBR) with a focus on patient-reported outcomes (PROMs). Methods This was a single-trust prospective quality improvement study conducted between 2017 and 2019. The main objectives were complication rates including infection, implant loss, and other surgical complications in patients undergoing TIGR mesh-assisted MIBR in the prepectoral plane for either cancer or risk reduction. PROMs were measured using the validated European Organisation for Research and Treatment of Cancer (EORTC) breast questionnaire module. Clinical evaluations were conducted at one week, three weeks, and 12 months postoperatively. All patients provided written consent, and the audit was registered with the Quality Improvement Department of the organization. Results One hundred and twelve meshes were used in 93 patients with a mean age of 49 (24-75) years and a body mass index (BMI) of 23.4 (19.1-29.6). During the follow-up period, complications occurred in 26 patients (28%), including infection in four (4.3%), complete skin flap necrosis in one (1%), partial flap necrosis in three (3.2%), and implant loss in four (4.3%) patients. PROM data from 41 individuals indicated a moderate overall quality of life (82.7%), with high functional domain scores with relatively lower emotional functioning scores. Symptom domains generally scored poorly except for body image and sexual functioning. Conclusion Mastectomy and immediate prepectoral breast reconstruction using TIGR mesh is safe with low major complication rates. It is associated with high functional and quality of life scores but low scores in symptom domains which could be multifactorial. However, limitations due to study type and follow-up duration suggest caution in generalizing findings.

Quantifying the Impact of Prepectoral Implant Conversion on Patient Satisfaction and Quality of Life

BACKGROUND

Conversion of subpectoral reconstruction to the prepectoral plane has been increasing in popularity. However, there is a paucity of research assessing patient-reported outcomes after this operation. The primary aim of this study was to examine patient-reported outcomes after conversion of implants from the subpectoral to prepectoral plane using the BREAST-Q.

METHODS

The authors retrospectively examined patients who underwent subpectoral-to-prepectoral implant conversion by three surgeons at two separate centers from 2017 through 2021. Patient demographics, primary indication for the conversion, surgical characteristics, postoperative outcomes, and BREAST-Q scores were obtained.

RESULTS

Sixty-eight breasts in 39 patients underwent implant conversion. The most common primary indications for implant conversion were chronic pain (41%), animation deformity (31%), and cosmetic concerns (28%). Average BREAST-Q scores improved significantly preoperatively to postoperatively in all the domains measured (satisfaction with breasts, satisfaction with implants, physical well-being, psychosocial well-being, and sexual well-being) ( P < 0.01). When examined by primary indication, all cohorts had significant preoperative to postoperative score improvement in satisfaction with breasts ( P < 0.001) and physical well-being ( P < 0.01) domains. Fifteen breasts (22%) developed postoperative complications, with implant loss in 9% of breasts.

CONCLUSIONS

Conversion of subpectoral implants to the prepectoral plane significantly improves BREAST-Q outcomes in all aspects, including patient satisfaction with breasts and implants, as well as psychosocial, physical, and sexual well-being. Implant conversion to the prepectoral plane is becoming the authors' primary solution for most patients with chronic pain, animation deformity, or cosmetic concerns after subpectoral reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction

BACKGROUND

Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss.

METHODS

A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss.

RESULTS

The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016).

CONCLUSION

Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

BACKGROUND

Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center.

METHODS

Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions.

RESULTS

A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months.

CONCLUSIONS

Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Prevention of Postoperative Complications by Prepectoral versus Subpectoral Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Implant-based breast reconstruction has evolved over time. However, the effects of prepectoral breast reconstruction (PBR) compared with those of subpectoral breast reconstruction (SBR) have not been clearly defined. Therefore, this study aimed to compare the occurrence of surgical complications between PBR and SBR to determine the procedure that is effective and relatively safe.

METHODS

The PubMed, Cochrane Library, and EMBASE databases were searched for studies published until April of 2021 comparing PBR and SBR following mastectomy. Two authors independently assessed the risk of bias. General information on the studies and surgical outcomes were extracted. Among 857 studies, 34 and 29 were included in the systematic review and meta-analysis, respectively. Subgroup analysis was performed to clearly compare the results of patients who underwent postmastectomy radiation therapy.

RESULTS

Pooled results showed that prevention of capsular contracture (OR, 0.57; 95% CI, 0.41 to 0.79) and infection control (OR, 0.73; 95% CI, 0.58 to 0.92) were better with PBR than with SBR. Rates of hematoma, implant loss, seroma, skin-flap necrosis, and wound dehiscence were not significantly different between PBR and SBR. PBR considerably improved postoperative pain, BREAST-Q score, and upper arm function compared with SBR. Among postmastectomy radiation therapy patients, the incidence rates of capsular contracture were significantly lower in the PBR group than in the SBR group (OR, 0.14; 95% CI, 0.05 to 0.35).

CONCLUSIONS

The results showed that PBR had fewer postoperative complications than SBR. The authors' meta-analysis suggests that PBR could be used as an alternative technique for breast reconstruction in appropriate patients.

Subpectoral Implant Placement Is Not Protective against Postmastectomy Radiotherapy-Related Complications Compared to Prepectoral Placement

BACKGROUND

Postmastectomy radiotherapy (PMRT) is associated with altered cosmetic outcomes and higher complication rates in implant-based breast reconstruction (IBR). Conventional wisdom suggests that muscle coverage is somewhat protective against PMRT-related complications. In this study, the authors compared surgical outcomes in patients who underwent two-stage prepectoral versus subpectoral IBR in the setting of PMRT.

METHODS

The authors performed a retrospective cohort study of patients who underwent mastectomy and PMRT with two-stage IBR from 2016 to 2019. The primary outcome was breast-related complications, including device infection; the secondary outcome was device explantation.

RESULTS

The authors identified 179 reconstructions (101 prepectoral and 78 subpectoral) in 172 patients with a mean follow-up time of 39.7 ± 14.4 months. There were no differences between the prepectoral and subpectoral reconstructions in rates of breast-related complications (26.7% and 21.8%, respectively; P = 0.274), device infection (18.8% and 15.4%, respectively; P = 0.307), skin flap necrosis (5.0% and 1.3%, respectively; P = 0.232), or device explantation (20.8% and 14.1%, respectively; P = 0.117). In adjusted models, compared with prepectoral device placement, subpectoral device placement was not associated with a lower risk of breast-related complications [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.41 to 1.36], device infection (HR, 0.73; 95% CI, 0.35 to 1.49), or device explantation (HR, 0.58; 95% CI, 0.28 to 1.19).

CONCLUSIONS

Device placement plane was not predictive of complication rates in IBR in the setting of PMRT. Two-stage prepectoral IBR provides safe long-term outcomes with acceptable postoperative complication rates comparable to those with subpectoral IBR, even in the setting of PMRT.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Immediate post-mastectomy prepectoral breast reconstruction with animal derived acellular dermal matrices: A systematic review

BACKGROUND

Animal-derived acellular dermal matrices (ADMs) are increasingly being used in prepectoral direct-to-implant (DTI) breast reconstruction. However, the indications and complication profile associated with this type of reconstruction remain unclear. This study aimed to perform a systematic review of the available literature on the use of animal-derived ADM in prepectoral DTI breast reconstruction.

METHODS

Three different literature databases, namely, PubMed, Web of Sciences, and Embase were screened using the following keywords: "immediate" AND "pre-pectoral" OR "prepectoral" AND "ADM breast reconstruction." Animal-derived ADM used (porcine - Braxon® and non-Braxon® - and bovine - Surgimend®) anthropometric information, clinical data, and complications profile were considered.

RESULTS

A total of 340 articles were initially identified, of which only 45 articles (5089 patients and 6598 reconstructed breasts) satisfied our inclusion criteria. The most widely used ADM was Braxon® in the context of conservative mastectomies. In most studies, a subcutaneous layer > 1 cm and lack of previous radiotherapy were considered prerequisites for this type of reconstruction. An increased risk of complications was found in smokers, patients who underwent radiation treatment, patients with high breast volumes, and patients with cancers requiring axillary dissection. Data related to the role of diabetes, high body mass index, and breast implant size on surgical outcomes were instead inconcludent. Age was not directly proportional to the complications.

CONCLUSION

The complications associated with different animal-derived ADMs are generally comparable. The profile of patients required for eligibility for this type of reconstruction appears to have been identified and is in line with current recommendations.

Surgical and Patient-Reported Outcomes of 694 Two-Stage Prepectoral versus Subpectoral Breast Reconstructions

BACKGROUND

Opinion regarding the optimal plane for prosthetic device placement in breast reconstruction patients has evolved. The purpose of this study was to assess the differences in complication rates and patient satisfaction between patients who underwent prepectoral and subpectoral implant-based breast reconstruction (IBR).

METHODS

The authors conducted a retrospective cohort study of patients who underwent two-stage IBR at their institution from 2018 to 2019. Surgical and patient-reported outcomes were compared between patients who received a prepectoral versus a subpectoral tissue expander.

RESULTS

A total of 694 reconstructions in 481 patients were identified (83% prepectoral, 17% subpectoral). The mean body mass index was higher in the prepectoral group (27 versus 25 kg/m 2 , P = 0.001), whereas postoperative radiotherapy was more common in the subpectoral group (26% versus 14%, P = 0.001). The overall complication rate was very similar, with 29.3% in the prepectoral and 28.9% in the subpectoral group ( P = 0.887). Rates of individual complications were also similar between the two groups. A multiple-frailty model showed that device location was not associated with overall complications, infection, major complications, or device explantation. Mean scores for Satisfaction with the Breast, Psychosocial Well-Being, and Sexual Well-Being were similar between the two groups. Median time to permanent implant exchange was significantly longer in the subpectoral group (200 versus 150 days, P < 0.001).

CONCLUSION

Prepectoral breast reconstruction results in similar surgical outcomes and patient satisfaction compared with subpectoral IBR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patient and procedure characteristics associated with postoperative pain after prophylactic versus therapeutic ambulatory bilateral breast surgery

BACKGROUND AND OBJECTIVES

We investigated whether age, body mass index (BMI), and tissue expander placement were related to postoperative opioid requirement for patients undergoing therapeutic versus prophylactic breast surgery.

METHODS

Postoperative opioid consumption was evaluated for patients who underwent bilateral mastectomy with immediate implant-based reconstruction at a freestanding ambulatory cancer surgery center between 2016 and 2021. Ordinal regression tested whether surgical indication was associated with increased postoperative opioid requirements after adjusting for age, BMI, and tissue expander placement.

RESULTS

Of 2447 patients, 6% underwent prophylactic surgeries. Therapeutic mastectomy patients had lower postoperative opioid requirement (OR = 0.67; 95% CI: 0.50-0.91; p = 0.030), but this was not significant after adjusting for covariates (OR = 0.75; 95% CI: 0.53-1.07; p = 0.2). Opioid use increased with higher BMI (OR = 1.06; 95% CI: 1.05-1.08; p < 0.001) and decreased with age (OR = 0.97; 95% CI: 0.96-0.98; p < 0.001) with therapeutic mastectomy patients being older (median 46 vs. 39). The subpectoral tissue expander group had nearly double the postoperative opioid requirement compared to prepectoral placement (OR = 1.86; 95% CI: 1.55-2.23; p < 0.001).

CONCLUSIONS

Increased postoperative opioid requirement in women undergoing prophylactic procedures is best explained by age. Mastectomy patients should be counseled similarly about postoperative pain irrespective of indication. A larger prophylactic mastectomy sample is required to provide more precise estimates.

ADM-Assisted Direct-to-Implant Prepectoral Breast Reconstruction in Postmastectomy Radiation Therapy Setting: Long-Term Results

BACKGROUND

Postmastectomy radiotherapy (PMRT) on immediate breast reconstruction historically involved a marked increase in complication rate (up to 50%). Prepectoral breast reconstruction (PPBR) has shown promising early postoperative results. This study aims to evaluate PPBR long-term results in PMRT setting.

MATERIALS AND METHODS

This is a retrospective monocentric analysis of 485 PPBR (439 patients) undergoing Acellular-Dermal-Matrix assisted direct-to-implant reconstruction (46 bilateral procedures) between January 2015 and December 2020 (mean FU:35.6 months). Group 1 comprised 401 PPBR not submitted to PMRT, and 84 reconstructions receiving PMRT in Group 2. Patients' characteristics, postoperative complication and revisional surgery rate were examined. PMRT characteristics and subcutaneous tissue thickness, measured in Group 2 by CT scan, were also evaluated.

RESULTS

Long-term complication rate was 11.2% in Group 1 vs. 21.4% in Group 2 (P-value = .019). Capsular contracture represented the only complication associated to a statistically significant difference between the 2 groups (P-value < .001). In Group 2, only 4.8% implant loss and 8.3% severe capsular contracture rate was found. In patients who underwent PMRT, 38.9% of complications settled with no consequences, and only 4.8% of patients needed revisional surgery in the long-term FU. According to multivariate analysis, drug intake and PMRT were significantly associated with postoperative complications. In Group 2, a thinner subcutaneous tissue was linked to a higher complication risk.

CONCLUSION

In our series, patients treated with PPBR who underwent PMRT, presented a low complication rate and minimal need for revisional surgery in the long-term follow-up, suggesting that this technique is feasible and safe also in PMRT context.

Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose?

Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.

Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction

BACKGROUND

The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established.

OBJECTIVES

The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane.

METHODS

We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation.

RESULTS

The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction.

CONCLUSIONS

Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes.

LEVEL OF EVIDENCE: 4

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Acellular dermal matrix in reconstructive surgery: Applications, benefits, and cost

Modern tissue engineering has made substantial advancements that have revolutionized plastic surgery. Acellular dermal matrix (ADM) is an example that has gained considerable attention recently. ADM can be made from humans, bovines, or porcine tissues. ADM acts as a scaffold that incorporates into the recipient tissue. It is gradually infiltrated by fibroblasts and vascularized. Fortunately, many techniques have been used to remove cellular and antigenic components from ADM to minimize immune system rejection. ADM is made of collagen, fibronectin, elastin, laminin, glycosaminoglycans, and hyaluronic acid. It is used in critical wounds (e.g., diabetic wounds) to protect soft tissue and accelerate wound healing. It is also used in implant-based breast reconstruction surgery to improve aesthetic outcomes and reduce capsule contracture risk. ADM has also gained attention in abdominal and chest wall defects. Some studies have shown that ADM is associated with less erosion and infection in abdominal hernias than synthetic meshes. However, its higher cost prevents it from being commonly used in hernia repair. Also, using ADM in tendon repair (e.g., Achilles tendon) has been associated with increased stability and reduced rejection rate. Despite its advantages, ADM might result in complications such as hematoma, seroma, necrosis, and infection. Moreover, ADM is expensive, making it an unsuitable option for many patients. Finally, the literature on ADM is insufficient, and more research on the results of ADM usage in surgeries is needed. This article aims to review the literature regarding the application, Benefits, and costs of ADM in reconstructive surgery.

Postmastectomy breast reconstruction for women with hereditary gastric and breast cancer syndrome

Post mastectomy reconstruction is nowadays an integral part of breast cancer treatment, usually performed in the immediate setting. Among women with hereditary gastric and breast cancer syndromes, three different scenarios can be identified. First, healthy women seeking for prophylactic mastectomies. Second, cancer patients requiring mastectomy at the tumor site and simultaneous risk reducing mastectomy of the healthy breast. Third, cancer patients who have been treated for primary cancer requiring risk reducing mastectomies in a further stage. In this paper, we present a schematic guide for reconstruction for each subpopulation of subjects and their peculiarities.

Clinical and Healthcare Resource Use Outcomes between Dual-plane and Prepectoral Techniques in Implant-based Breast Reconstruction: A Multicenter Retrospective Study

This multicenter, retrospective study compared clinical outcomes and healthcare resource use in patients who underwent dual-plane (DP) or prepectoral (PP) implant-based breast reconstruction (IBR) after mastectomy in the United States.

Methods

Medical records were selected for patients at five sites undergoing immediate one-stage direct-to-implant (first hospitalization) or two-stage IBR (first and second hospitalization) using either DP or PP. Inverse probability of treatment weighting was used to adjust for potential confounders. Complications and healthcare resource use were assessed with logistic regression; pain severity was assessed with ordinary least-squares regression.

Results

After inverse probability of treatment weighting, data from 255 patients (DP = 130, PP = 125) and 441 breasts (DP = 226, PP = 215) were analyzed. Mean pain severity scores were lower with PP versus DP immediately after IBR for first (P = 0.0002) and second hospitalizations (P = 0.0145), and before discharge for first (P < 0.0001) and second hospitalizations (P = 0.0002). A greater proportion of PP versus DP patients had a shorter hospital length of stay (≤ 23 hours) for first hospitalization (P = 0.0052); proportions were similar for second hospitalization (P = 0.5499). Intravenous narcotics were prescribed less frequently to PP versus DP patients during first (61.1% versus 69.8%, respectively; P = 0.1486) and second (37.5% versus 55.3%, respectively; P = 0.0172) hospitalizations. Complication rates were low in both groups after first hospitalization discharge (DP: 13.6%, PP: 12.5%, P = 0.7225).

Conclusion

This retrospective study suggests that the PP technique in IBR may offer benefits related to clinical outcomes and health resource utilization; however, larger studies, including randomized controlled trials, are needed to confirm.

Immediate Prepectoral Breast Reconstruction Using an ADM with Smooth Round Implants – A Prospective Observational Cohort Study

Prepectoral breast reconstruction using acellular dermal matrices (ADMs) is well established and used in candidates for nipple/skin-sparing mastectomies; it is based on many different matrices and a great variability in breast implant selection. We describe our experience and clinical outcomes using Braxon® ADMs and smooth round breast implants. Females aged 18-80 years who underwent mastectomies with immediate prepectoral reconstruction between April 2019 and April 2021 were prospectively included. Complications were classified as mastectomy-related (hematoma, necrosis) or reconstruction-related (seroma, infection, red breast syndrome). Binary logistic regression analysis was performed to assess correlation between complication rate and selected variables, which were analyzed per breast with Kruskal-Wallis H test. Fifty-eight patients (102 breasts) received 45 bilateral and 12 unilateral procedures. Drains collected 485.9 cc [range: 100-1260] and were removed 15.7 days [range: 6-29] postoperatively. We report 41 complications (40.2%): 33 mastectomy-related, 8 reconstruction-related. Reoperation occurred in 14 patients: 7 wound debridement and revisions under local anesthesia; and 7 explantation. Implant loss rate was 6.8%. Mastectomy and reconstruction complications were not correlated with any variable. In conclusion, we found prepectoral reconstruction with Braxon® ADMs and smooth round implants to be associated with acceptable complication rates that are not influenced by any patient- or surgery-related factors. Drainage volume is comparable to other breast implant reconstructive techniques, but drains are left in place for longer.

A descriptive comparison of satisfaction and well-being between expander-based and direct-to-implant breast reconstruction after Nipple-Sparing Mastectomy

BACKGROUND

The literature that has explored differences between direct-to-implant (DTI) and expander-based (EB) breast reconstruction has mainly focused on complications, with results not always unambiguous. Moreover, there are limited data 1) comparing DTI and EB breast reconstruction after nipple-sparing mastectomy (NSM) and 2) from the patient's perspective.

AIM

The aim of this study was to compare satisfaction and well-being in patients undergoing DTI and EB reconstruction after NSM in a Comprehensive Cancer Center, exploring what factors can be related to satisfaction and well-being.

METHOD

The study design is monocentric, observational and retrospective. The participants completed an online questionnaire containing the Breast-Q and some socio-demographic variables (year of birth, level of education, civil status). Clinical information was obtained from the institutional database. Surgical techniques in the two branches of NSM were similar: all skin incisions, lateral to the areola; all implants, subpectoral (EB: conventionally submuscular; DTI: dual-plane pocket); all without synthetic mesh or acellular tissue matrix.

RESULTS

A total of 120 patients (45% with EB and 55% with DTI) completed the questionnaire. We found that there are no differences between EB and DTI concerning the satisfaction and well-being of NSM patients, except for satisfaction with information, which is greater in the DTI group. In EB patients, no variables among those explored are related to satisfaction and well-being. In DTI patients, level of education is positive related to satisfaction with implants and physical well-being, Tumor-Node-Metastasis (TNM) and body mass index (BMI) are negative related to satisfaction with information and TNM also with satisfaction for plastic surgery.

CONCLUSION

EB and DTI do not differ in terms of patient well-being, but EB requires a more careful counselling by the surgeon.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

One-Stage Immediate Alloplastic Breast Reconstruction in Large and Ptotic Breasts: An Institutional Algorithm

Immediate implant-based breast reconstruction in patients with large and ptotic breasts may be challenging due to skin redundancy. The use of a reduction mammoplasty pattern for the mastectomy skin excision has proven to be a reliable option for these patients as it allows for a better shape, projection, and symmetrization. This approach has been described in the literature for both one- and two-stage reconstruction with either sub- or pre-pectoral reconstruction with an acellular dermal matrix (ADM) or non-biological mesh. One-stage immediate breast reconstructions have a positive significant impact on patients' psychosocial well-being and quality of life. The purpose of this paper is to describe an institutional algorithm that allows one to perform one-stage implant-based breast reconstructions in patients with large and ptotic breasts.

Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life

BACKGROUND

The use of direct-to-implant subcutaneous breast reconstruction has increased over the last years. The goal of this systematic review is to deliver an updated review of the safety of this technique and its impact on quality of life. We also compare subcutaneous vs submuscular complications, through meta-analysis.

METHODS

Literature review through PubMed and Cochrane Library databases were performed by PRISMA criteria. Thirty-nine studies met inclusion criteria for subcutaneous review and 15 studies met inclusion criteria for meta-analysis. All included studies were evaluated for complications and answers to the BREAST-Q. Data were analysed using Microsoft Excel, IBM SPSS, and Cochrane RevMan.

RESULTS

In 2863 patients and 3988 breasts that undergone direct to implant subcutaneous breast reconstruction, 8,21% had rippling, 5,64% seroma, 1,74% hematoma, 3,40% infection, 3,01% wound dehiscence, 3,93% skin necrosis, 3,34% nipple-areolar-complex (NAC) necrosis, 3,07% capsular contracture, 0,00% animation deformity, and 3,83% an implant removal. Meta-analysis showed a statistically significant decrease in the odds ratio of animation deformity, a but statistically significant higher odds ratio of rippling. Subcutaneous and submuscular reconstructions had similar BREAST-Q scores.

CONCLUSIONS

Direct-to-implant subcutaneous breast reconstruction does not harm the patient's quality of life, comparatively with submuscular, saving the pectoral muscle from dissection and preventing animation deformity, but increasing the risk of rippling.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients

BACKGROUND

The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR.

METHODS

A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research.

RESULTS

Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010).

CONCLUSIONS

The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.

Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Systemic Review and Meta-analysis

BACKGROUND

Implant-based breast reconstruction (IBBR) remains the standard and most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral IBBR has resurged in popularity, despite limited data comparing prepectoral with subpectoral IBBR.

METHODS

A systematic search of PubMed and Cochrane Library from January 1, 2011 to December 31, 2021, was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines, data were extracted by independent reviewers. Studies that compared prepectoral with subpectoral IBBR for breast cancer were included.

RESULTS

Overall, 15 studies with 3,101 patients were included in this meta-analysis. Our results showed that patients receiving prepectoral IBBR experienced fewer capsular contractures (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.32-0.92; P = 0.02), animation deformity (OR, 0.02; 95% CI, 0.00-0.25; P = 0.002), and prosthesis failure (OR, 0.58; 95% CI, 0.42-0.80; P = 0.001). There was no significant difference between prepectoral and subpectoral IBBR in overall complications (OR, 0.83; 95% CI, 0.64-1.09; P = 0.19), seroma (OR, 1.21; 95% CI, 0.59-2.51; P = 0.60), hematoma (OR, 0.76; 95% CI, 0.49-1.18; P = 0.22), infection (OR, 0.87; 95% CI, 0.63-1.20; P = 0.39), skin flap necrosis (OR, 0.70; 95% CI, 0.45-1.08; P = 0.11), and recurrence (OR, 1.31; 95% CI, 0.52-3.39; P = 0.55). Similarly, no significant difference was found in Breast-Q scores between the prepectoral and subpectoral IBBR groups.

CONCLUSIONS

The results of our systematic review and meta-analysis demonstrated that prepectoral, implant-based, breast reconstruction is a safe modality and has similar outcomes with significantly lower rates of capsular contracture, prosthesis failure, and animation deformity compared with subpectoral, implant-based, breast reconstruction.

Prepectoral Breast Reconstruction Reduces Opioid Consumption and Pain After Mastectomy: A Head-to-Head Comparison With Submuscular Reconstruction

BACKGROUND

Acute pain after mastectomy is increased with concurrent breast reconstruction. One postulated advantage of prepectoral breast reconstruction is less postoperative pain; however, no comparisons to partial submuscular reconstruction have been made to date. Here, we examined the postoperative pain experienced between patients with prepectoral and subpectoral breast reconstruction after mastectomy.

METHODS

We performed a retrospective chart review of all patients undergoing immediate breast reconstruction with tissue expanders from 2012 to 2019 by a single plastic surgeon. Patient demographics, surgical details, and anesthetic techniques were evaluated, and our primary outcome compared postoperative opioid usage between prepectoral and subpectoral reconstructions. Our secondary outcome compared pain scores between techniques.

RESULTS

A total of 211 subpectoral and 117 prepectoral reconstruction patients were included for analysis. Patients with subpectoral reconstructions had higher postoperative opioid usage (80.0 vs 45.0 oral morphine equivalents, P < 0.001). Subpectoral patients also recorded higher maximum pain scores compared with prepectoral reconstructions while admitted (7 of 10 vs 5 of 10, P < 0.004). Multivariable linear regression suggests that mastectomy type and subpectoral reconstruction were significant contributors to postoperative opioid use (P < 0.05).

CONCLUSIONS

Prepectoral breast reconstruction was associated with less postoperative opioid consumption and lower postoperative pain scores as compared with subpectoral reconstruction, when controlling for other surgical and anesthesia factors. Future randomized controlled trials are warranted to study how postoperative pain and chronic pain are influenced by the location of prosthesis placement in implant-based postmastectomy breast reconstruction.

Braxon®-assisted prepectoral breast reconstruction: A decade later

We are sitting on the cusp of the bioengineered breast era, in which implant-based breast reconstruction is seeing a growing trend and biotechnology research progressively empowers clinical practice. As never before, the choice of biomaterials has acquired great importance for achieving reconstructive outcomes, and the increase in the use of acellular dermal matrices (ADMs) in the field of senology tells us a story of profound upheaval and progress. With the advent of prepectoral breast reconstruction (PPBR), plenty of devices have been proposed to wrap the silicone prosthesis, either completely or partially. However, this has caused a great deal of confusion and dissent with regard to the adoption of feasible reconstructive strategies as well as the original scientific rationale underlying the prepectoral approach. Braxon^® is the very first device that made prepectoral implant positioning possible, wrapping around the prosthesis and exerting the proven ADM regenerative potential at the implant–tissue interface, taking advantage of the body's physiological healing mechanisms. To date, the Braxon^® method is among the most studied and practiced worldwide, and more than 50 publications confirm the superior performance of the device in the most varied clinical scenarios. However, a comprehensive record of the working of this pioneering device is still missing. Therefore, our aim with this review is to lay a structured knowledge of surgery with BRAXON^® and to provide a decision-making tool in the field of PPBR through a complete understanding on the very first device for prepectoral, one decade after its introduction.

A prospective comparison of prepectoral and subpectoral methods for immediate breast reconstruction with acellular dermal matrix: the cogwheel-shaped anterior wrapping method

Background Prepectoral breast reconstruction has recently gained wide recognition for its advantages, such as rapid recovery and less pain. This study compared the effectiveness of and differences between the prepectoral and subpectoral breast reconstruction techniques.Methods Eighty-three patients (90 breasts) who underwent prepectoral or subpectoral breast reconstruction surgery between January 2019 and December 2020 were prospectively recruited. Patient demographics, comorbidities, oncological treatment, and intraoperative and postoperative data were evaluated to investigate the validity and stability of each surgical technique. The follow-up period was a minimum of 18 months.Results The surgical cohorts (22 prepectoral and 68 subpectoral) had comparable demographics. No significant differences in postoperative complications were observed between the two groups. The prepectoral group showed shorter operation times than the subpectoral group (mean: 97.27 and 127.63 minutes, respectively; P<0.001). Fewer days elapsed until drain removal and the total amount of drainage was less in the prepectoral group than in the subpectoral group (mean: postoperative day [POD] 8.95 and 10.06, respectively; P=0.048) and (501.72 mL and 671.19 mL, respectively; P=0.009). The numeric pain rating scale (NPRS) scores at POD 7 were significantly lower in the prepectoral group than in the subpectoral group (mean: 0.41 and 1.82, respectively; P=0.029). There were no statistically significant differences in the NPRS scores at POD 1 or the BREAST-Q questionnaire scores at 3 months.Conclusions Prepectoral breast reconstruction using acellular dermal matrix can feasibly replace the conventional subpectoral breast reconstruction technique and has the advantages of reducing operation time, length of hospitalization, and long-term postoperative pain.

Cost analysis of pre-pectoral implant-based breast reconstruction

With improvement in mastectomy skin flap viability and increasing recognition of animation deformity following sub-pectoral implant placement, there has been a transition toward pre-pectoral breast reconstruction. While studies have explored the cost effectiveness of implant-based breast reconstruction, few investigations have evaluated cost with respect to pre-pectoral versus sub-pectoral breast reconstruction. A retrospective review of 548 patients who underwent mastectomy and implant-based breast reconstruction was performed from 2017 to 2020. The demographic and surgical characteristics of the pre-pectoral and sub-pectoral cohorts were well matched, except for reconstructive staging, as patients who underwent pre-pectoral reconstruction were more likely to undergo single-stage instead of two-stage reconstruction. Comparison of institutional cost ratios by reconstructive technique revealed that the sub-pectoral approach was more costly (1.70 ± 0.44 vs 1.58 ± 0.31, p < 0.01). However, further stratification by laterality and reconstructive staging failed to demonstrate difference in cost by reconstructive technique. These results were confirmed by multivariable linear regression, which did not reveal reconstructive technique to be an independent variable for cost. This study suggests that pre-pectoral breast reconstruction is a cost-effective alternative to sub-pectoral breast reconstruction and may confer cost benefit, as it is more strongly associated with direct-to-implant breast reconstruction.

Immediate prosthetic breast reconstruction after removal of the polyacrylamide hydrogel (PAAG) through a small areolar incision assisted with an endoscope

Background

To identify the feasibility, safety, cosmetic outcomes and patient satisfaction of immediate prosthetic breast reconstruction after removal of Polyacrylamide Hydrogel (PAAG) through a small areolar incision assisted with an endoscope.

Methods

This was a retrospective study. Medical records of 87 patients who underwent PAAG removal were reviewed retrospectively from February 2010 to December 2019. These patients were dichotomized based on whether they accepted immediate prosthetic breast reconstruction after PAAG removal or not. A comprehensive analysis on the data was conducted to observe the surgical results, cosmetic outcomes, health-related quality of life (HRQOL) and patient satisfaction.

Results

Sixty-two patients underwent PAAG removal through a small areolar incision assisted with an endoscope, while another 25 patients underwent further immediate prosthetic breast reconstruction after PAAG removal. All the patients recovered smoothly after operation. In the immediate breast reconstructed group, most of the breasts were natural in appearance, but one patient had mild nipple and breast asymmetry, and another had mild breast asymmetry. Three patients had PAAG residual, and one of them accepted fine needle aspiration. The cosmetic satisfaction rate was 88% and 92% by surgeons and patients, respectively. In the other group, seven patients suffered from PAAG residual, one patient suffered from postoperative bleeding, and five patients suffered from skin laxity. The BREAST-Q scores revealed that patients who accepted immediate breast reconstruction had significant better outcomes in psychosocial well-being (p = 0.030), satisfaction with breasts (p = 0.021), when compared to patients who only accepted PAAG removal, while similar in sexual well-being (p = 0.081), physical well-being chest (p = 0.124), and satisfaction with outcomes (p = 0.068), and satisfaction with care (p = 0.077).

Conclusion

Immediate prosthetic breast reconstruction after PAAG removal through a small areolar incision aided with an endoscope might be a viable and safe technique, with better psychosocial well-being and satisfaction with breasts.

Novel three-dimensional acellular dermal matrix for prepectoral breast reconstruction: First year in review with BRAXON®Fast

Implant-based breast reconstruction is part of breast cancer treatment, and increasingly optimized reconstructive procedures exploit highly biocompatible materials to ensure enhanced aesthetic-functional results. Acellular dermal matrices (ADMs) are collagen-based materials that made prepectoral implant placement possible, thanks to their bioactive antifibrosis action. Recently, the first three-dimensional ADM, BRAXON^®Fast, has been produced. Its 3D design represents the technological evolution of BRAXON^® ADM, a flat collagen matrix, and allows for a time-saving complete wrapping of the synthetic prosthesis, thus creating a total biological interface on the implant with patient's tissues. Here, we report our experience on the first 23 eligible patients who received BRAXON^®Fast-assisted prepectoral reconstruction. On a total of 27 breasts, the overall complication rate was 11.1%, including one minor seroma (3.7%), one case of necrosis (3.7%), and one implant removal due to infection. As new-generation devices, 3D ADMs showed an effective performance, allowing to reduce the overall exposure time for implant preparation and providing an optimal safety profile.

Evaluation of Breast Animation Deformity following Pre- and Subpectoral Direct-to-Implant Breast Reconstruction: A Randomized Controlled Trial

Background  The incidence of breast animation deformity (BAD) is reported to be substantial after direct-to-implant breast reconstruction with subpectoral implant placement. It has, however, never been examined if BAD can occur following prepectoral implant placement. Our primary aim was to compare the incidence and degree of BAD after direct-to-implant breast reconstruction using either subpectoral or prepectoral implant placement. Secondary aim of this study was to assess and compare the level of pain between sub- and prepectoral reconstructed women. Methods  In this randomized controlled trial, patients were allocated to reconstruction by either subpectoral or prepectoral implant placement in accordance with the CONSORT guidelines. The degree of BAD was assessed by the "Nipple, Surrounding skin, Entire breast (NSE)" grading scale 12 months after surgery. The level of postoperative pain was assessed on a numerical pain rating scale. Results  We found a significant difference in the degree of BAD favoring patients in the prepectoral group (23.8 vs. 100%, p  < 0.0001; mean NSE grading scale score: 0.4 vs. 3.6, p  < 0.0001). The subpectoral reconstructed group reported higher levels of pain on the three subsequent days after surgery. No significant difference in pain levels could be found at 3 months postoperatively. Conclusion  The incidence and degree of BAD was significantly lower in women reconstructed by prepectoral direct-to-implant breast reconstruction. Unexpectedly, we found mild degrees of BAD in the prepectoral group. When assessing BAD, distortion can be challenging to discern from rippling.

Comparison of Outcomes Following Prepectoral and Subpectoral Implants for Breast Reconstruction: Systematic Review and Meta-Analysis

(1) Background: Implant-based breast reconstruction following mastectomy helps to restore quality of life while aiming at providing optimal cosmetic outcomes. Both prepectoral (PP) and subpectoral (SP) breast implants are widely used to fulfill these objectives. It is, however, unclear which approach offers stronger postoperative benefits. (2) Methods: We performed a systematic review of the literature through PubMed, Cochrane Library, and ResearchGate, following the PRISMA guidelines. Quantitative analysis for postoperative pain as the primary outcome was conducted. Secondary outcomes included patient satisfaction and postoperative complications such as seroma, implant loss, skin necrosis, wound infection, and hematoma. (3) Results: Nine articles involving 1119 patients were retrieved. Our results suggested increased postoperative pain after SP implants and significantly higher rates of seroma following PP implants (p < 0.05). Patient satisfaction was found to be similar between the two groups; however, the heterogeneity of measurement tools did not allow us to pool these results. The rates of implant loss, skin necrosis, wound infection, and hematoma showed no significant differences between the two cohorts. (4) Conclusion: Our data suggest that both implant placements are safe and effective methods for breast reconstruction following mastectomy. However, homogeneity in outcome measurements would allow one to provide stronger statistical results.

Pre-Pectoral One-Stage Breast Reconstruction with Anterior Coverage Using Superior Anterior Biological Acellular Dermal Matrix (ADM) and Inferior Anterior Dermal Sling Support

The use of acellular dermal matrix (ADM) implants has enhanced breast reconstruction. ADM is a biotechnologically designed human tissue of bovine or porcine origin in which tissue processing removes cellular antigens. In this case report, we describe the use of ADM in one-stage prepectoral breast reconstruction. Skin-reduction breast reconstruction with a prepectoral implant was performed. We created a combined dermal pocket using the inferior dermal flap, sutured with a patch of acellular dermal matrix to continue its extension until the upper pole, to cover the implant. This technique offers single-stage immediate reconstruction, with a decreased requirement for ADM and increased use of vascularized tissue and implant support. Additionally, in the pre-pectoral space, decreased pain postoperatively and less anatomic disruption is offered.

Prepectoral breast reconstruction with complete anterior implant coverage using a single, large, square-shaped acellular dermal matrix

BACKGROUND

Several studies have discussed various methods of prepectoral direct-to-implant (DTI) breast reconstruction using an acellular dermal matrix (ADM) prosthesis to achieve full coverage. However, methods for anterior coverage have rarely been reported. In this study, prepectoral DTI breast reconstruction with complete anterior implant coverage was performed using a square piece of ADM. This study aimed to introduce our prepectoral DTI technique and determine its functional and cosmetic outcomes as well as compare them with those of existing subpectoral DTI techniques.

METHODS

This prospective comparative study focused on 29 patients (35 breasts) and 34 patients (35 breasts) who underwent breast reconstruction via subpectoral implant insertion (control group) and anterior coverage prepectoral implant insertion (anterior coverage group), respectively. Postoperative complications were noted, and breast symmetry was evaluated using the Vectra H2 three-dimensional scanner. The modified Kyungpook National University Hospital Breast-Q (KNUH Breast-Q) scale was used to assess the patient's subjective satisfaction with the reconstruction and postoperative quality of life.

RESULTS

No remarkable differences in terms of complications (seroma, skin necrosis, nipple-areola complex necrosis, hematoma, capsular contracture, and infection) were noted in both groups. Compared with controls, considerably better results were observed among those in the anterior coverage group in terms of the mean drain removal period. Furthermore, those in the anterior coverage group showed greater symmetry on three-dimensional scans than the controls; however, this was not statistically significant. Subjective satisfaction and postoperative quality of life measured using the KNUH Breast-Q scale were not significantly different between both groups.

CONCLUSIONS

Considering its stability, faster recovery time, and cosmetic benefit, prepectoral breast reconstruction with anterior implant coverage using a single, large ADM is a good choice to perform breast reconstruction with implant insertion in patients who have undergone mastectomy.

LEVEL OF EVIDENCE

II.

Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study

BACKGROUND

We sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss.

METHODS

Total submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons.

RESULTS

A total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24).

CONCLUSIONS

Prepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study

BACKGROUND

Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here.

METHODS

Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection.

RESULTS

Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction.

CONCLUSION

Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.

Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis

Women undergoing implant-based reconstruction (IBR) after mastectomy for breast cancer have numerous options, including timing of IBR relative to radiation and chemotherapy, implant materials, anatomic planes, and use of human acellular dermal matrices. We conducted a systematic review to evaluate these options.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies, from inception to March 23, 2021, without language restriction. We assessed risk of bias and strength of evidence (SoE) using standard methods.

Results

We screened 15,936 citations. Thirty-six mostly high or moderate risk of bias studies (48,419 patients) met criteria. Timing of IBR before or after radiation may result in comparable physical, psychosocial, and sexual well-being, and satisfaction with breasts (all low SoE), and probably comparable risks of implant failure/loss or explantation (moderate SoE). No studies addressed timing relative to chemotherapy. Silicone and saline implants may result in clinically comparable satisfaction with breasts (low SoE). Whether the implant is in the prepectoral or total submuscular plane may not impact risk of infections (low SoE). Acellular dermal matrix use probably increases the risk of implant failure/loss or need for explant surgery (moderate SoE) and may increase the risk of infections (low SoE). Risks of seroma and unplanned repeat surgeries for revision are probably comparable (moderate SoE), and risk of necrosis may be comparable with or without human acellular dermal matrices (low SoE).

Conclusions

Evidence regarding IBR options is mostly of low SoE. New high-quality research is needed, especially for timing, implant materials, and anatomic planes of implant placement.

Quality of life, pain of prepectoral and subpectoral implant-based breast reconstruction with a discussion on cost: A systematic review and meta-analysis

INTRODUCTION

Prepectoral implant-based breast reconstruction (PIBR) has regained popularity, despite decades-long preference for subpectoral implant placement. This paper aims to compare patient-reported outcomes (PRO) between prepectoral and subpectoral approaches to implant-based breast reconstruction (IBBR). The primary PRO was with the BREAST-Q, and postoperative pain scores, while the secondary outcomes were complication rates.

METHODS

A comprehensive literature search of the PubMed library was performed. All studies on patients undergoing IBBR after mastectomy that compared prepectoral to subpectoral placement and PROM or postoperative pain were included.

RESULTS

A total of 3789 unique studies of which 7 publications with 216 and 332 patients who received prepectoral and subpectoral implants, respectively, were included for meta-analysis. Patients with prepectoral implant placement had significantly higher satisfaction with the outcome (p = 0.03) and psychosocial well-being (p = 0.03) module scores. The pain was lower in patients with prepectoral implants on postoperative day 1 (p<0.01) and day 7 (p<0.01). The subgroup analysis of prepectoral breast implants showed that complete acellular dermal matrix coverage had lower rates of wound dehiscence (p<0.0001), but there were no significant differences in complications between one-stage and two-stage procedures.

CONCLUSION

Overall, patients with prepectoral implants reported higher BREAST-Q scores and lower postoperative pain and lower complications rates than patients with subpectoral implants. In appropriately selected patients, prepectoral implant placement with ADM coverage, be it the primary placement of an implant or placement of a tissue expander before definitive implant placement, should be the modality of choice in patients who choose IBBR. Further research should focus on patient selection, strategies to reduce cost and cost-benefit analysis of PIBR.

Prepectoral and Subpectoral Tissue Expander-Based Breast Reconstruction: A Propensity-Matched Analysis of 90-Day Clinical and Health-Related Quality-of-Life Outcomes

BACKGROUND

Prepectoral placement of tissue expanders for two-stage implant-based breast reconstruction potentially minimizes chest wall morbidity and postoperative pain. The authors explored 90-day clinical and health-related quality-of-life outcomes for prepectoral versus subpectoral tissue expander breast reconstruction.

METHODS

The authors conducted a propensity score-matching analysis (nearest neighbor, 1:1 matching without replacement) of patients who underwent immediate prepectoral or subpectoral tissue expander breast reconstruction between December of 2017 and January of 2019. Matched covariates included age, body mass index, race/ethnicity, smoking status, chemotherapy, radiotherapy, nipple-sparing mastectomy, and laterality of reconstruction. Outcomes of interest were perioperative analgesia use, 90-day postoperative patient-reported pain, complication rates, and BREAST-Q physical well-being of the chest scores.

RESULTS

Of the initial cohort of 921 patients, 238 were propensity-matched and included in the final analysis. The matched cohort had no differences in baseline characteristics. Postoperative ketorolac (p = 0.048) use was higher in the subpectoral group; there were no other significant differences in intraoperative and postoperative analgesia use. Prepectoral patients had lower pain on postoperative days 1 to 2 but no differences on days 3 to 10. BREAST-Q physical well-being of the chest scores did not differ. Prepectoral patients had higher rates of seroma than subpectoral patients (p < 0.001). Rates of tissue expander loss did not differ.

CONCLUSIONS

This matched analysis of 90-day complications found lower early postoperative pain in prepectoral tissue expander patients but no longer-term patient-reported differences. Although prepectoral reconstruction patients experienced a higher rate of seroma, this did not translate to a difference in tissue expander loss. Long-term analysis of clinical and patient-reported outcomes is needed to understand the full profile of the prepectoral technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction

BACKGROUND

Increasing amounts of acellular dermal matrix are being used with the adoption of prepectoral breast reconstruction. Postoperative infection remains a challenge in breast reconstruction, and the contribution of acellular dermal matrix type, processing, and sterility assurance level to risk of complications in prepectoral reconstruction is not well studied.

METHODS

The authors performed a retrospective review of patients who underwent immediate prepectoral breast reconstruction from February of 2017 to July of 2020. Because of an increase in the rate of infection, the drain protocol was changed and acellular dermal matrix type was switched from AlloDerm (sterility assurance level, 10-3) to DermACELL (sterility assurance level, 10-6) in January of 2019. Demographic and surgical variables were collected, in addition to details regarding development and management of infection.

RESULTS

Despite higher rates of direct-to-implant reconstruction and bilateral procedures and increased implant volumes, the rate of infection was significantly lower in patients who received DermACELL instead of AlloDerm [two of 38 (5.3 percent) versus 11 of 41 (26.8 percent); p = 0.014]. Drain duration was slightly longer in the DermACELL group, consistent with the change in drain protocol. Baseline demographic and clinical characteristics remained similar between the two groups.

CONCLUSIONS

With increased reliance on large amounts of acellular dermal matrix for prepectoral breast reconstruction, it directly follows that the properties of acellular dermal matrix with respect to incorporation, sterility, and implant support are that much more important to consider. There have been few studies comparing different types of acellular dermal matrix in prepectoral breast reconstruction, and further research is required to determine the contribution of acellular dermal matrix type and processing techniques to development of postoperative infection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy

BACKGROUND

Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques.

METHODS AND ANALYSIS

Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN10081873.

Prepectoral breast reconstruction: an ideal approach to bilateral risk-reducing mastectomy

Background

Bilateral risk-reducing mastectomy (BRRM) has increased its popularity in the last years because of its aim to minimise the chances of developing breast cancer in high-risk patients. Women undergoing this procedure must be considered highly demanding patients given the need to combine aesthetical, functional and preventive desires. This study aims to present the authors' experience in performing BRRM followed by single-stage prepectoral reconstruction (PPBR) with implant completely covered by acellular dermal matrix (ADM) and to report indications, surgical techniques, functional and aesthetic results.

Methods

A single-centre prospective data collection was carried out from January 2017 to January 2021 of patients at high risk of developing breast cancer undergoing BRRM and immediate PPBR with ADM. Patients were subdivided into two groups according to the breast shape: Group A had small and medium size breasts and Group B had large and ptotic breasts. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through the BREAST-Q questionnaire.

Results

A total of twenty-three patients met the inclusion criteria. Seventeen patients were included in group A and six patients in group B. Average follow-up was 18.4 months. Minor complications occurred in four breasts: one seroma, one hematoma and two cases of wound dehiscence. Capsular contracture was not observed. All patients were satisfied with the final result according to the post-operative BREAST-Q questionnaire.

Conclusions

Immediate prepectoral breast reconstruction could represent the ideal reconstruction option after BRRM and should be offered to all women that fulfil the inclusion criteria.

Comparing post-surgical outcomes of pre-pectoral versus dual-plane direct-to-implant breast reconstruction without increasing the use of acellular dermal matrix

BACKGROUND

Direct-to-implant (DTI) reconstruction when performed using the dual-plane technique can be associated with increased postoperative pain, longer recovery, functional impairment, and animation deformity. These issues can be avoided by using the pre-pectoral technique that traditionally uses larger pieces of the acellular dermal matrix (ADM) and results in increased costs. It is unclear how these two methods compare when the technique is modified to avoid the use of additional ADM.

METHODS

A retrospective chart review was conducted of all patients who underwent DTI breast reconstruction using a dual-plane or pre-pectoral technique between January 2014 and December 2019. Pre-pectoral breast reconstruction was performed using a partial anterior coverage technique, and therefore no additional ADM was used per case as compared to the dual-plane technique. Rates of post-surgical complications were compared between the two groups.

RESULTS

Of 77 patients, 48 (86 breasts) underwent dual-plane reconstruction, whereas 29 (48 breasts) underwent pre-pectoral reconstruction. Mean follow-up time for the dual-plane and pre-pectoral groups was 23.3 and 8.7 months, respectively (p<0.001). There were no significant differences in the rates of any of the short-term post-surgical outcomes between the two groups: seroma (14% vs 6.3%, p = 0.175); hematoma (2.3% vs 4.2%, p = 0.617); skin/nipple necrosis (7% vs 10.4%, p = 0.522); wound skin infection (2.3% vs 2.1%, p = 1.0); wound dehiscence (4.7% vs 2.1, p = 0.654); and implant loss (1.2% vs 8.3%, p = 0.055).

CONCLUSIONS

Pre-pectoral reconstruction using a partial anterior coverage technique appears to be a safe alternative to dual-plane reconstruction when considering short-term post-surgical complications.

Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update

Background:

Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction.

Methods:

This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included.

Results:

Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction.

Conclusions:

Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.