Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction

Comparing outcomes of prepectoral, partial muscle-splitting subpectoral, and dual-plane subpectoral direct-to-implant reconstruction: implant upward migration and the pectoralis muscle

Background

Although dual-plane subpectoral breast reconstruction has been widely implemented in implant-based breast reconstruction, animation deformities remain an issue. Recent advances in skin flap circulation detection have increased the use of prepectoral reconstruction. A partial muscle-splitting subpectoral plane was introduced to decrease the visibility of the implant edge. However, there is yet to be a direct comparison of these methods for optimal results, including changes in implant position after reconstruction. This study aims to compare the incidence of complications such as rippling, animation deformity, implant upward migration between the dual-plane, the partial muscle splitting subpectoral and the prepectoral reconstruction group. In addition, multivariate analysis was conducted to identify the risk factors of complications.

Methods

We retrospectively investigated 349 patients who underwent unilateral direct-to-implant breast reconstruction from January 2017 to October 2020. Implants were inserted into the dual-plane subpectoral (P2) or partial muscle-splitting subpectoral (P1, the muscle slightly covering the upper edge of the implant) or the prepectoral pocket (P0). Postoperative outcomes and at least 2 years of follow-up complications were compared.

Results

There was no significant difference in rippling (P=0.62) or visible implant edges on the upper pole (P=0.62) among the three groups. In contrast, the P0 group had a lower incidence of seroma (P=0.008), animation deformity (P<0.001), breast pain (P=0.002), and upward implant migration (P0: 1.09%, P1: 4.68%, P2: 38.37%, P<0.001). According to the multivariate analysis, P2 resulted in a greater risk of seroma (odds ratio: 4.223, P=0.002) and implant upward migration (odds ratio: 74.292, P<0.001) than did P0.

Conclusions

P0 and P1 showed better postoperative outcomes than P2. Additionally, P0 had less implant migration than P1. Even though P1 minimally dissects the muscle, the location of the implant may change. Considering that muscle contraction can deteriorate symmetry and aesthetic results, the P0 method may be the most favorable.

Impact of Tissue Expander Surface Texture on Two-Stage Breast Reconstruction Outcomes: A Combined Analysis

BACKGROUND

With ongoing investigations of the impact of device texturing on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), studies have begun comparing complication profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study was to provide a comparative survival analysis of postoperative complications between smooth (STEs) and textured tissue expanders (TTEs) in breast reconstruction.

METHODS

A single-institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year after second-stage reconstruction from 2014 to 2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, Cox proportional hazard models, and a consensus-based ordinal logistic regression model were used to compare complication profiles.

RESULTS

Of 919 total patients, 600 (65.3%) received TTEs and 319 (34.7%) received STEs. There was increased risk of infection ( P < 0.0001), seroma ( P = 0.046), expander malposition ( P < 0.0001), and wound dehiscence ( P = 0.019) in STEs compared with TTEs. However, there was also a decreased risk of capsular contracture ( P = 0.005) in STEs compared with TTEs. Failure of breast reconstruction ( P < 0.001) and wound dehiscence ( P = 0.018) occurred significantly earlier in STEs compared with TTEs. Predictors for significantly higher severity complications included the following: smooth tissue expander use ( P = 0.007), shorter time to complication ( P < 0.0001), higher body mass index ( P = 0.005), smoking history ( P = 0.025), and nipple-sparing mastectomy ( P = 0.012).

CONCLUSIONS

Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated with increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Single-center Comparison of Surgical Outcomes following Prepectoral and Subpectoral Implant-based Breast Reconstruction

Background

Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Current literature demonstrates comparable rates of complications and revisions between prepectoral and subpectoral placement; however, these studies are underpowered and lack long-term follow-up.

Methods

We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. The primary outcomes were postoperative complications, aesthetic deformities, and secondary revisions. Descriptive statistics and multivariable regression models were performed to compare the demographic characteristics and outcomes between the two cohorts.

Results

We identified 996 breasts (570 patients), which were divided into prepectoral (391 breasts) and subpectoral (605 breasts) cohorts. There was a higher rate of complications (P < 0.001) and aesthetic deformities (P = 0.02) with prepectoral breast reconstruction. Secondary revisions were comparable between the two cohorts. Multivariable regression analysis confirmed that prepectoral reconstruction was associated with an increased risk of complications (odds ratio 2.39, P < 0.001) and aesthetic deformities (odds ratio 1.62, P = 0.003).

Conclusions

This study evaluated outcomes in patients undergoing prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication and aesthetic profile compared with subpectoral placement, with no difference in secondary revisions. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.

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.

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.

The Effect of Early Cultures and Dual-port Expanders on Two-stage, Prepectoral Breast Reconstruction: The 25/25 Study

Background

Two-stage tissue expander to implant surgery remains the predominant technique for breast reconstruction. Unfortunately, there is a high incidence of reconstruction failure which portends a financial and emotional burden. Most failures are related to postmastectomy skin flap necrosis and infection. Recently, a dual-port tissue expander was introduced to the market, and the authors hypothesize that early cultures from the peri-implant fluid will guide antibiotic treatment and decrease reconstruction failure.

Methods

This is a cohort study of 50 consecutive patients treated for breast cancer or genetic susceptibility via a two-stage, prepectoral technique. The first 25 patients (46 breasts) were treated with a variety of tissue expanders, and the subsequent 25 patients (47 breasts) received a dual-port expander. Routine cultures from the drain port were taken from the dual-port group at the second postoperative visit, and cultures were taken in the control group only when signs of infection were present. All other procedures and interventions were similar.

Results

Fifty patients, totaling 93 breasts, completed the study with a mean follow-up of 145 days. There were no statistically significant demographic or pathologic differences between groups. Fifteen tissue expanders were explanted in the control group and five in the dual-port cohort (32.6% versus 10.6%, P = 0.012). All bacteria in the control group failures were either methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis, whereas failures in the dual-port group varied.

Conclusion

Treatment of routine, early cultures from a dual-port expander led to a statistically significant decrease in tissue expander explantation.

Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review

Background and Objective

With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO).

Methods

For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023.

Key Content and Findings

Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies.

Conclusions

Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.

Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction

INTRODUCTION

Pre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR.

METHODS

A literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction.

RESULTS

Implant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling.

CONCLUSION

Surgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction.

LEVEL OF EVIDENCE V

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 .

Methodological Quality of Open Access Compared to Traditional Journal Publications in the Plastic Surgery Literature

BACKGROUND

The methodological quality of open access studies has long been questioned due to increasing popularity and accessibility. The objective of this study is to compare the methodological quality of open access versus traditional journal publications in the plastic surgery literature.

METHODS

Four traditional plastic surgery journals with their sister open access journals were chosen. For each of the eight journals, 10 articles were randomly selected for inclusion. Methodological quality was examined using validated instruments. Publication descriptors were compared to methodological quality values using ANOVA. Logistic regression was used to compare quality scores between open access and traditional journals.

RESULTS

There was a wide distribution of levels of evidence, with a quarter being level one. Regression of non-randomized studies indicated a significantly higher proportion of traditional journal articles were of high methodological quality (89.6%) when compared to open access journals (55.6%; p < 0.05). This difference persisted in three quarter of the sister journal groups. No publication descriptions were associated with methodological quality.

CONCLUSIONS

Methodological quality scores were higher among traditional access journals. Higher degrees of peer review may be necessary to ensure appropriate methodological quality in open access plastic surgery publications.

LEVEL OF EVIDENCE V

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 .

Patient-reported outcomes: A primer for plastic surgeons

Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs.

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.

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.

Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes

BACKGROUND

Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR.

METHODS

A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented.

RESULTS

After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p > 0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p = 0.001). The intraoperative expansion volumes were higher in the prepectoral group (300 ml versus 200 ml, p = 0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p = 0.58).

CONCLUSION

Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.

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.