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Talwar AA, Lanni MA, Ryan IA, Kodali P, Bernstein E, McAuliffe PB, Broach RB, Serletti JM, Butler PD, Fosnot J. Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes. Plast Reconstr Surg 2024; 153:281e-290e. [PMID: 37159266 DOI: 10.1097/prs.0000000000010618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Ankoor A Talwar
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Michael A Lanni
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Isabel A Ryan
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Pranav Kodali
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Elizabeth Bernstein
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Phoebe B McAuliffe
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Robyn B Broach
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Joseph M Serletti
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Paris D Butler
- Division of Plastic Surgery, Department of Surgery, Yale Medicine
| | - Joshua Fosnot
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
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Tevlin R, Sharma AD, Griffin M, Wan D, Momeni A. Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction. Aesthetic Plast Surg 2023; 47:2351-2359. [PMID: 37704858 DOI: 10.1007/s00266-023-03616-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/10/2023] [Indexed: 09/15/2023]
Abstract
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 .
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Affiliation(s)
- Ruth Tevlin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- Royal College of Surgeons in Ireland, St Stephen's Green, Dublin, Ireland
| | - Ayushi Dutt Sharma
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Michelle Griffin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- Royal College of Surgeons in Ireland, St Stephen's Green, Dublin, Ireland
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA.
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Cazzato V, Scarabosio A, Bottosso S, Rodda A, Vita L, Renzi N, Caputo G, Ramella V, Parodi PC, Papa G. Early Seroma Treatment Protocol Based on US-Guided Aspiration in DTI Prepectoral Reconstruction: A Prospective Study. Clin Breast Cancer 2023; 23:e542-e548. [PMID: 37806916 DOI: 10.1016/j.clbc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Seroma is a common complication after prepectoral prosthetic breast reconstruction with ADM, leading to wound dehiscencse, infection, and even loss of reconstruction at last. A new ultrasound (US) guided follow-up protocol has been applied to compare primary and secondary complications incidence and their treatment, and evaluate the effect of precocious seroma detection and its evacuation in reducing secondary complications. METHODS We enrolled 406 patients from January 1st, 2021 to July 1st, 2023 who underwent mastectomy and 1-stage prepectoral reconstruction with ADM. Experimental group counted 96 patients, whom have been treated as protocol fashion, therefore with multiple US-guided evaluations and eventual evacuations along with postoperative period; control group (310 patients) has exclusively been clinically evaluated. RESULTS Seroma incidence detected rate among experimental group, after 1-year follow-up, was 32.2%, compared to 16.8% in control cohort, additionally no other secondary complications were detected in the first group. Referring to the wound dehiscence incidence, a statistically significant higher frequency was observed in control group compared with treatment 1 (21.2% vs. 0%; P = .0027). CONCLUSIONS Seroma and correlated secondary complications may lead to additional surgeries, higher sanitary costs and even reconstructive failure. With a seriated US follow-up protocol application, the surgeon could promptly manage and treat seroma, decreasing additional complications rate, particularly wound dehiscence. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Vito Cazzato
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Anna Scarabosio
- Department of Medical Area (DIME), Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Stefano Bottosso
- Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
| | - Agostino Rodda
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Ludovica Vita
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Nadia Renzi
- Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
| | - Glenda Caputo
- Department of Medical Area (DIME), Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Vittorio Ramella
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Pier Camillo Parodi
- Department of Medical Area (DIME), Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, University of Udine, Udine, Italy.
| | - Giovanni Papa
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy; Department of Plastic and Reconstructive Surgery, Azienda Sanitaria Universitaria Giuliano-Isontina, Trieste University Hospital, Trieste, Italy
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Tellarini A, Garutti L, Corno M, Tamborini F, Paganini F, Fasoli V, Di Giovanna D, Valdatta L. Immediate post-mastectomy prepectoral breast reconstruction with animal derived acellular dermal matrices: A systematic review. J Plast Reconstr Aesthet Surg 2023; 86:94-108. [PMID: 37716255 DOI: 10.1016/j.bjps.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/01/2023] [Accepted: 08/13/2023] [Indexed: 09/18/2023]
Abstract
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.
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Affiliation(s)
- Annachiara Tellarini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
| | - Leonardo Garutti
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Martina Corno
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Federico Tamborini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Microsurgery and Hand Surgery Unit, ASST Settelaghi Varese, Varese, Italy
| | - Ferruccio Paganini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Veronica Fasoli
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Danilo Di Giovanna
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Luigi Valdatta
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Ryu DH, Joo OY, Roh YH, Yang EJ, Song SY, Lee DW. Associated Factors and Prevention of Upper Pole Rippling in Prepectoral Direct-to-Implant Breast Reconstruction. Arch Plast Surg 2023; 50:541-549. [PMID: 38143837 PMCID: PMC10736204 DOI: 10.1055/a-2125-7322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/21/2023] [Indexed: 12/26/2023] Open
Abstract
Background Despite its many advantages, prepectoral breast reconstruction also carries the risk of implant rippling. The recent introduction of partial superior implant coverage using a pectoralis muscle slip in prepectoral direct-to-implant (DTI) breast reconstruction has shown the potential to minimize upper pole rippling. The purpose of this study was to identify factors associated with rippling and the effectiveness of our surgical technique. Methods In total, 156 patients (186 breasts) who underwent prepectoral DTI breast reconstruction between August 2019 and March 2021 were identified retrospectively. Patient data were analyzed from medical records. Univariable and multivariable logistic analyses were performed to contextualize the risks associated with rippling deformity relative to demographic characteristics and other clinical factors. Retrospective propensity-matched analysis was performed to identify the relationship between rippling deformity and the reconstruction method. Results Patients with body mass index (BMI; odds ratio [OR], 0.736; p < 0.001), those with a postoperative chemotherapy history (OR, 0.324; p = 0.027) and those who received breast reconstruction via the superior coverage technique (OR, 0.2; p = 0.004), were less likely to develop rippling deformity. The median follow-up period was 64.9 weeks, and there were no significant differences between patients in types of mastectomy, implant, or acellular dermal matrix. Patients who underwent superior coverage technique-based reconstruction showed significantly reduced rippling (OR, 0.083; p = 0.017) Conclusion Patients with higher BMI and prior postoperative chemotherapy were less likely to develop rippling deformity. The superior coverage technique can be effective in minimizing upper pole rippling.
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Affiliation(s)
- Da Hye Ryu
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Oh Young Joo
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Yang
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Han WY, Han SJ, Eom JS, Kim EK, Han HH. A Comparative Study of Wraparound versus Anterior Coverage Placement of Acellular Dermal Matrix in Prepectoral Breast Reconstruction. Plast Reconstr Surg 2023; 152:716-724. [PMID: 36862962 DOI: 10.1097/prs.0000000000010347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Prepectoral direct-to-implant insertion (DTI) with acellular dermal matrix (ADM) is the currently preferred operation for breast reconstruction. There are different placements of ADM, which are largely classified as wraparound placement or anterior coverage placement. Because there are limited data comparing these two placements, this study aimed to compare the outcomes of these two methods. METHODS This was a retrospective study of immediate prepectoral DTI breast reconstructions performed by a single surgeon between 2018 and 2020. Patients were classified depending on the ADM placement type used. Surgical outcomes and breast shape changes using nipple position during follow-up were compared. RESULTS A total of 159 patients were included in the study, with 87 in the wraparound group and 72 in the anterior coverage group. Demographics were similar between the two groups, excluding ADM amount used (154.1 cm 2 versus 137.8 cm 2 ; P = 0.01). There were no significant differences in the overall rate of complications between the two groups, including seroma (6.90% versus 5.56%; P = 1.0), total drainage amount (762.1 mL versus 805.9 mL; P = 0.45), and capsular contracture (4.6% versus 1.39%; P = 0.38). The wraparound group had a significantly longer distance change than that of the anterior coverage group in the sternal notch-to-nipple distance (4.44% versus 2.08%; P = 0.03) and midclavicle-to-nipple distance (4.94% versus 2.64%; P = 0.04). CONCLUSIONS Wraparound and anterior coverage placement of ADM in prepectoral DTI breast reconstruction showed similar complication rates, including seroma, drainage amount, and capsular contracture. However, wraparound placement can make the breast more ptotic in shape compared with anterior coverage placement. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Woo Yeon Han
- From the Department of Plastic and Reconstructive Surgery, Yongin Severance Hospital, Yonsei University College of Medicine
| | - Seong John Han
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jin Sup Eom
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Eun Key Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyun Ho Han
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Sohn SM, Lee HC, Park SH, Yoon ES. Difference in the outcomes of anterior tenting and wrapping techniques for acellular dermal matrix coverage in prepectoral breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 85:266-275. [PMID: 37536194 DOI: 10.1016/j.bjps.2023.06.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Acellular dermal matrices (ADMs) play an essential role in prepectoral implant-based breast reconstructions; however, the most appropriate method for ADMs is unknown. METHODS We conducted a retrospective analysis of our institutional database. Patients who underwent mastectomy and prepectoral breast reconstruction using tissue expanders or breast implants covered with ADMs between March 2018 and June 2021 were included. Patient characteristics, postoperative complications, and long-term outcomes were investigated. RESULTS In total, 112 patients (126 breasts) were included. The anterior tenting and wrapping techniques were used in the reconstruction of 32 (25.3%) and 94 (74.7%) breasts, respectively. Using propensity score matching, nine breasts were selected for each technique within the direct-to-implant reconstruction group, while 16 breasts were selected for each technique within the 2-stage reconstruction group. The choice of technique (anterior vs. wrapping) in implementing ADM did not generate any significant differences in postoperative complications, including seroma formation and capsular contracture, for the direct-to-implant and 2-stage reconstruction groups. Regarding the direct-to-implant reconstruction group, the average postoperative drain volume was less in the anterior tenting group than that in the wrapping group (anterior tenting vs. wrapping; 495.09 ± 156.118 mL vs. 673.43 ± 307.954 mL, p = 0.006), but the difference was insignificant after propensity score matching. CONCLUSION We report our experience with covering prosthetic devices with ADMs during postmastectomy breast reconstruction. No differences in the postoperative drain volume or postoperative outcomes were found between the study groups. Future studies are needed to determine the method that provides the most satisfactory results.
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Affiliation(s)
- Sung-Min Sohn
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Seoul, Republic of Korea.
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Pel E, Engelberts I, Schermer M. Diversity of interpretations of the concept "patient-centered care for breast cancer patients"; a scoping review of current literature. J Eval Clin Pract 2022; 28:773-793. [PMID: 34002460 PMCID: PMC9788211 DOI: 10.1111/jep.13584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 12/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Patient-centered care is considered a vital component of good quality care for breast cancer patients. Nevertheless, the implementation of this valuable concept in clinical practice appears to be difficult. The goal of this study is to bridge the gap between theoretical elaboration of "patient-centered care" and clinical practice. To that purpose, a scoping analysis was performed of the application of the term "patient-centered care in breast cancer treatment" in present-day literature. METHOD For data-extraction, a literature search was performed extracting references that were published in 2018 and included the terms "patient-centered care" and "breast cancer". The articles were systematically traced for answers to the following three questions: "What is patient-centered care?", "Why perform patient-centered care?", and "How to realize patient-centered care?". For the content analysis, these answers were coded and assembled into meaningful clusters until separate themes arose which concur with various interpretations of the term "patient-centered care". RESULTS A total of 60 publications were retained for analysis. Traced answers to the three questions "what", "why", and "how" varied considerably in recent literature concerning breast cancer treatment. Despite the inconsistent use of the term "patient-centered care," we did not find any critical consideration about the nature of the concept, regardless of the applied interpretation. Interventions that are supposed to contribute to the heterogeneous concept of patient-centered care as such, seem to be judged desirable, virtually without empirical justification. CONCLUSIONS We propose, contrary to previous efforts to define "patient-centered care" more accurately, to embrace the heterogeneity of the concept and apply "patient-centered care" as an umbrella-term for all healthcare that intends to contribute to the acknowledgement of the person in the patient. For the justification of measures to realize patient-centered care for breast cancer patients, instead of a mere contribution to the abstract concept, we insist on the demonstration of desirable real-world effects.
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Affiliation(s)
- Elise Pel
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center of Rotterdam, Rotterdam, The Netherlands
| | - Ingeborg Engelberts
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center of Rotterdam, Rotterdam, The Netherlands.,The Franciscus Breast Clinic, Department of Surgery, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Maartje Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center of Rotterdam, Rotterdam, The Netherlands
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Kim HI, Kim BS, Park JH, Yi HS, Kim HY, Choi JH, Jung SU, Kim YS. "Tear-Drop Appearance" Wrap: A Novel Implant Coverage Method for Creating Natural Contour in Prepectoral Prosthetic-Based Breast Reconstruction. J Clin Med 2022; 11:jcm11154592. [PMID: 35956207 PMCID: PMC9370020 DOI: 10.3390/jcm11154592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Various implant wrapping methods with acellular dermal matrix (ADM) have been introduced, but most focus on random trimming and suturing aimed to maximize implant coverage. Here we present our clinical experience using a “tear-drop appearance” wrapping method to achieve natural contours through upper pole volume replacement. We retrospectively reviewed the data of 56 consecutive cases of prepectoral prosthetic-based breast reconstruction (PPBR) using this wrapping method following nipple-sparing mastectomy between March 2020 and June 2021. The “tear-drop appearance” wrapping design creates an anatomical tear-drop–shaped pocket to encourage lower pole fullness and create a natural contour through upper pole volume replacement by ADM. Patients’ baseline characteristics, operative data, and complications were analyzed. Aesthetic outcomes were measured using the BREAST-Q and Aesthetic Item Scale (AIS). A successful reconstruction was achieved without major complications and using a single ADM sheet. Four types and three sizes of ADMs were used. The mean resected breast tissue weight was 274.3 g, while the mean implant volume was 230.0 cc. The average BREAST-Q and AIS scores were 4.6 ± 0.8 and 4.5 ± 0.7, respectively. Owing to its simplicity, reproducibility, and effectivity, this method is an excellent implant coverage option that achieves a natural contour in PPBR.
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Affiliation(s)
- Hong-il Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Byeong-seok Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Jin-hyung Park
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Hyung-suk Yi
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Hyo-young Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Jin-hyuk Choi
- Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Sung-ui Jung
- Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Yoon-soo Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
- Correspondence: ; Tel.: +82-51-990-6131
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Hybrid Prepectoral Direct-to-Implant and Autologous Fat Graft Simultaneously in Immediate Breast Reconstruction: A Single Surgeon's Experience with 25 Breasts in 15 Consecutive Cases. Plast Reconstr Surg 2022; 149:386e-391e. [PMID: 35196670 DOI: 10.1097/prs.0000000000008879] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The direct-to-implant method depends on the quality of the mastectomy flaps and can be used only when the flaps are adequately perfused. Even though the method was designed to be a definitive reconstruction procedure, it has been associated with an increased likelihood that additional operative revision will be required in order to achieve the expected final cosmetic outcome. The authors describe a hybrid prepectoral direct-to-implant method that combines autologous fat grafting in the superior medial pole with immediate reconstruction. METHODS In this prospective study, 15 patients (25 reconstructed breasts) underwent simultaneous hybrid prepectoral direct-to-implant reconstruction together with autologous fat grafting performed by a single senior plastic surgeon (Y.G). RESULTS The mean quantity of autologous fat grafted in the superior medial aspect of the breast was 59.4 ± 12.8 cc. The mean total volume of the hybrid reconstructed breast, including implant and autologous fat graft, was 497.2 ± 89.1 cc. Satisfying final outcomes were achieved in all cases. There were no major complications, although minor complications were observed. CONCLUSIONS The authors' hybrid approach allows the surgeon to achieve a more satisfying outcome with regard to the cleavage area. It results in a better natural appearance, an improved contour, and reduced upper pole rippling and deflation, with a lower likelihood that an additional operative revision will be required to achieve the desired final aesthetic outcome. The authors believe that their hybrid approach should be implemented as an integral part of the direct-to-implant prepectoral reconstruction procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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11
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Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3825. [PMID: 34712539 PMCID: PMC8547925 DOI: 10.1097/gox.0000000000003825] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 12/29/2022]
Abstract
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.
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12
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Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options. Semin Plast Surg 2021; 35:181-188. [PMID: 34526866 PMCID: PMC8432995 DOI: 10.1055/s-0041-1731464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.
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Affiliation(s)
- Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward M. Reece
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Peter G. Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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13
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The "Empanada" Construct: Prepectoral Technique Refinement Utilizing a Composite Acellular Dermal Matrix Mesh Wrap. Plast Reconstr Surg 2021; 147:1082-1083. [PMID: 33961614 DOI: 10.1097/prs.0000000000007934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Jeon DN, Kim J, Ko BS, Lee SB, Kim EK, Eom JS, Han HH. Robot-assisted breast reconstruction using the prepectoral anterior tenting method. J Plast Reconstr Aesthet Surg 2021; 74:2906-2915. [PMID: 34023241 DOI: 10.1016/j.bjps.2021.03.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 03/12/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Prosthetic breast reconstruction in the prepectoral plane with acellular dermal matrix (ADM) support has been gaining popularity and the use of robotic assistance could enhance this procedure. This study introduces robot-assisted prosthetic breast reconstruction using the anterior tenting method. METHODS Sixteen patients (16 breasts) undergoing surgery from July 2019 to April 2020 were included in this study. The breast oncology team performed mastectomies with direct-to-implant (DTI) reconstruction using the da Vinci XiTM (Intuitive Surgical Corp., Sunnyvale, CA, USA) system. The prepectoral plane anterior tenting method using ADM was performed. RESULTS Of the 16 patients, 14 underwent a nipple-sparing mastectomy and two underwent a skin-sparing mastectomy. The average patient age was 44.9 years, body mass index (BMI) was 22.9 kg/m2, and mastectomy weight was 367.6 g. The breast oncology team had an average operating time of 194.7 minutes, and the plastic surgery team had an average operating time of 80.8 minutes. The average postoperative drainage was 943.6 mL, and minor complications occurred in two patients. CONCLUSION With the robot, only a small incision of approximately 4.5 cm is necessary and areas that are not readily visible, such as the side of the axilla, can be accessed during the surgery. Using a smaller ADM size, the implant pocket under the ADM can be easily created under a magnified view. Inframammary fold (IMF) restoration is also possible with robotic surgery and delayed bleeding from the pocket can be easily controlled.
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Affiliation(s)
- Dong Nyeok Jeon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Jin Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Hyun Ho Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea.
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Khan A, Tasoulis MK, Teoh V, Tanska A, Edmonds R, Gui G. Pre-pectoral one-stage breast reconstruction with anterior biological acellular dermal matrix coverage. Gland Surg 2021; 10:1002-1009. [PMID: 33842244 DOI: 10.21037/gs-20-652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Pre-pectoral implant breast reconstruction (IBR) is gaining popularity. Several techniques using different types of meshes and methods of placement have been described, but no method is currently considered standard. The aim of this study was to evaluate the outcomes of pre-pectoral IBR using acellular dermal matrix (ADM) for anterior implant cover. Methods Retrospective cohort study of consecutive patients who underwent pre-pectoral IBR between November 2016 to August 2018. Data on demographics, adjuvant therapies and operative technique was collected. Postoperative complications, length of hospital stay and secondary cosmetic procedures were recorded. Statistical analysis was performed using descriptive statistics, non-parametric tests and logistic regression. Results One hundred and eleven pre-pectoral IBR were performed in 65 patients. Median age was 41 [interquartile range (IQR), 35-51.5] years, and BMI 22 (IQR, 20.4-24.4) kg/m2. Therapeutic mastectomy was performed in 33 procedures with nipples preservation in 78 cases. The median mastectomy weight and implant volume was 360 (IQR, 220-533) gr, and 445 (IQR, 400-475) cc respectively. At a median follow-up of 18 (IQR, 12-22.5) months, 37 mastectomies had at least 1 complication, but only 12 required surgery. The implant loss rate was 4.5% (5 cases). Lipofilling as secondary procedure was performed in 10.8% of cases. Factors associated with post-operative complications on univariate analysis were nipple preservation (P=0.028), BMI (P=0.01) and implant volume (P=0.027) but these did not remain significant on multivariate analysis. Conclusions Pre-pectoral IBR using ADM for anterior implant cover is associated with low complication and reconstructive failure rate. Patient selection and meticulous surgical technique are important for successful outcome.
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Affiliation(s)
- Ayesha Khan
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Victoria Teoh
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aleksandra Tanska
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ruth Edmonds
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gerald Gui
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
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Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience. Aesthetic Plast Surg 2021; 45:51-60. [PMID: 32860077 PMCID: PMC7886728 DOI: 10.1007/s00266-020-01892-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/19/2020] [Indexed: 11/30/2022]
Abstract
Background The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dual-plane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates. Materials and Methods A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retro-pectoral muscular position + ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded. Results We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were pre-pectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma. Conclusion Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries. 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. Electronic supplementary material The online version of this article (10.1007/s00266-020-01892-y) contains supplementary material, which is available to authorized users.
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Bozzuto LM, Bartholomew AJ, Tung S, Sosin M, Tambar S, Cox S, Perez-Alvarez IM, King CA, Chan MC, Pittman TA, Tousimis EA. Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1763-1769. [PMID: 33451949 DOI: 10.1016/j.bjps.2020.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 10/18/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prepectoral (PP) breast reconstruction is now commonly performed and minimizes dissection of the pectoralis major muscle. Data are lacking comparing the immediate postoperative recovery of these patients as compared with traditional subpectoral (SP) breast reconstruction. METHODS From December 2015 to February 2017, 73 patients underwent PP prosthetic-based reconstruction at a single academic institution. PP cases were matched 1:1, by age and stage, to patients undergoing traditional SP reconstruction. Analysis of postoperative pain (visual analog scale) and opioid use (oral morphine equivalents, OME), was performed with both bi- and multivariate analyses. Additional outcomes explored included length of stay (LOS) and reconstructive intervention by plane of prosthetic reconstruction. RESULTS A total of 146 patients were included in the final cohort. PP reconstruction was associated with higher rates of direct-to-implant reconstruction (84.9% vs. 34.3%, p <0.001) and higher rates of initial prosthetic fill (401.53 mL vs. 280.88 mL, p<0.001). Patients undergoing PP reconstruction had significantly reduced postoperative pain (4.29 vs. 5.44, p<0.001) and in-hospital opioid use (62.63 mg OME vs. 98.84 mg OME, p = 0.03) compared with SP patients. This result remained in multivariate analysis for both pain (3.94 vs. 5.25, p<0.001) and opioid use (17.14 mg OME vs. 63.03 mg OME, p = 0.03). Additionally, patients undergoing PP reconstruction had significantly reduced overall LOS on multivariate analysis (21.36 vs. 26.28 h, p = 0.02). CONCLUSION Following mastectomy, PP breast reconstruction results in significantly reduced pain, opioid use, and hospital LOS compared with SP reconstruction.
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Affiliation(s)
- Laura M Bozzuto
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Alex J Bartholomew
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Shawndeep Tung
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Michael Sosin
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Stuti Tambar
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Comprehensive Blood and Cancer Center, Bakersfield, CA, United States
| | - Solange Cox
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Idanis M Perez-Alvarez
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Caroline A King
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Mabel C Chan
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Troy A Pittman
- Somenek+Pittman MD Advanced Plastic Surgery, Washington, DC, United States
| | - Eleni A Tousimis
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States.
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18
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Avila A, Bartholomew AJ, Sosin M, Deldar R, Griffith KF, Willey SC, Song DH, Fan KL, Tousimis EA. Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy. Plast Reconstr Surg 2020; 146:715e-720e. [PMID: 33234947 DOI: 10.1097/prs.0000000000007326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement. METHODS A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes. RESULTS A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange. CONCLUSIONS Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Azalia Avila
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Alex J Bartholomew
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Michael Sosin
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Romina Deldar
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Kayla F Griffith
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Shawna C Willey
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - David H Song
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Kenneth L Fan
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Eleni A Tousimis
- From the Department of Surgery, Division of Breast Surgery, and the Department of Plastic Surgery, MedStar Georgetown University Hospital; and the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
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Cuomo R. Submuscular and Pre-Pectoral ADM Assisted Immediate Breast Reconstruction: A Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E256. [PMID: 32466619 PMCID: PMC7353845 DOI: 10.3390/medicina56060256] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022]
Abstract
Background and objectives: Breast cancer treatment has deeply changed in the last fifty years. Acellular dermal matrices (ADMs) were introduced for breast reconstruction, with encouraging results, but with conflicting reports too. The present paper aims to summarize the current data on breast reconstruction using acellular dermal matrices. Materials and Methods: We reviewed the literature regarding the use of ADM-assisted implant-based breast reconstruction. Results: The main techniques were analyzed and described. Conclusions: Several authors have recently reported positive results. Nevertheless, an increased complications' rate has been reported by other authors. Higher cost compared to not-ADM-assisted breast reconstruction is another concern.
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Affiliation(s)
- Roberto Cuomo
- Santa Maria Alle Scotte Hospital, Plastic and Reconstructive Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Mario Bracci Street, 53100 Siena, Italy
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20
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Nealon KP, Weitzman RE, Sobti N, Gadd M, Specht M, Jimenez RB, Ehrlichman R, Faulkner HR, Austen WG, Liao EC. Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcome Endpoints and Delineation of Risk Factors. Plast Reconstr Surg 2020; 145:898e-908e. [PMID: 32332523 DOI: 10.1097/prs.0000000000006721] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continued evolution of implant-based breast reconstruction involves immediate placement of the implant above the pectoralis muscle. The shift to prepectoral breast reconstruction is driven by goals of decreasing morbidity such as breast animation deformity, range-of-motion problems, and pain, and is made possible by improvements in mastectomy skin flap viability. To define clinical factors to guide patient selection for direct-to-implant prepectoral implant reconstruction, this study compares safety endpoints and risk factors between prepectoral and subpectoral direct-to-implant breast reconstruction cohorts. The authors hypothesized that prepectoral direct-to-implant breast reconstruction is a safe alternative to subpectoral direct-to-implant breast reconstruction. METHODS Retrospective chart review identified patients who underwent prepectoral and subpectoral direct-to-implant breast reconstruction, performed by a team of five surgical oncologists and two plastic surgeons. Univariate analysis compared patient characteristics between cohorts. A penalized logistic regression model was constructed to identify relationships between postoperative complications and covariate risk factors. RESULTS A cohort of 114 prepectoral direct-to-implant patients was compared with 142 subpectoral direct-to-implant patients. The results of the penalized regression model demonstrated equivalence in safety metrics between prepectoral direct-to-implant and subpectoral direct-to-implant breast reconstruction, including seroma (p = 0.0883), cancer recurrence (p = 0.876), explantation (p = 0.992), capsular contracture (p = 0.158), mastectomy skin flap necrosis (p = 0.769), infection (p = 0.523), hematoma (p = 0.228), and revision (p = 0.122). CONCLUSIONS This study demonstrates that prepectoral direct-to-implant reconstruction is a safe alternative to subpectoral direct-to-implant reconstruction. Given the low morbidity and elimination of animation deformity, prepectoral direct-to-implant reconstruction should be considered when the mastectomy skin flap is robust. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Kassandra P Nealon
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Rachel E Weitzman
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Nikhil Sobti
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Michele Gadd
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Michelle Specht
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Rachel B Jimenez
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Richard Ehrlichman
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Heather R Faulkner
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - William G Austen
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Eric C Liao
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
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22
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Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to–Inframammary Fold Measurement. Plast Reconstr Surg 2020; 145:251e-262e. [DOI: 10.1097/prs.0000000000006439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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The Broad Application of Prepectoral Direct-to-Implant Breast Reconstruction with Acellular Dermal Matrix Drape and Fluorescent Imaging in a Community Setting. Plast Reconstr Surg 2020; 145:291-300. [PMID: 31985606 DOI: 10.1097/prs.0000000000006496] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Optimizing Outcomes in 2-Stage Prepectoral Breast Reconstruction Utilizing Round Form-Stable Implants. Plast Reconstr Surg 2019; 144:43S-50S. [DOI: 10.1097/prs.0000000000005949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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26
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Evolution of the Surgical Technique for “Breast in a Day” Direct-to-Implant Breast Reconstruction. Plast Reconstr Surg 2019; 143:1547-1556. [DOI: 10.1097/prs.0000000000005627] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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An Algorithmic Approach to Prepectoral Direct-to-Implant Breast Reconstruction. Plast Reconstr Surg 2019; 143:1311-1319. [DOI: 10.1097/prs.0000000000005519] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fracol M, Qiu CS, Feld LN, Chiu WK, Kim JYS. Myotomy-Capsulotomy With Intramuscular Fat Grafting: A Novel Technique for Secondary Treatment of Prepectoral Upper Pole Defects in Breast Reconstruction. Aesthet Surg J 2019; 39:454-459. [PMID: 30395150 DOI: 10.1093/asj/sjy305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Megan Fracol
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Cecil S Qiu
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lauren N Feld
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Wen-Kuan Chiu
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taiwan
- Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
| | - John Y S Kim
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Jones G, Antony AK. Single stage, direct to implant pre-pectoral breast reconstruction. Gland Surg 2019; 8:53-60. [PMID: 30842928 PMCID: PMC6378250 DOI: 10.21037/gs.2018.10.08] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/24/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction. METHODS The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed. RESULTS The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longer-term follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time. CONCLUSIONS The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.
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Affiliation(s)
- Glyn Jones
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Anuja K. Antony
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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30
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The Suture Tab Technique: Securing Implant Position in Prepectoral Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e2005. [PMID: 30656107 PMCID: PMC6326603 DOI: 10.1097/gox.0000000000002005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/19/2018] [Indexed: 11/26/2022]
Abstract
Human acellular dermal matrix (ADM) can augment prepectoral prosthetic-based direct-to-implant breast reconstruction by providing an additional soft-tissue layer between breast implant and skin, as well as to reinforce the inframammary fold and breast pocket. Utilizing ADM in this way has helped reduce rates of implant rippling, capsular contracture, and implant extrusion. Difficulty in securing ADM-wrapped implants has caused many surgeons to improvise techniques for secure implantation. Here, we describe a simple technique for creating suture tabs within the ADM for efficient fixation of the ADM-implant construct to the chest wall.
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31
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The "Butterfly" Wrap: A Simplified Technique for Consistent Prosthesis Coverage in Prepectoral Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e2007. [PMID: 30881801 PMCID: PMC6414108 DOI: 10.1097/gox.0000000000002007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
Background: Here, we describe our simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral breast reconstruction. Methods: Our Butterfly Wrap is a simple technique, which provides prosthesis coverage with a single sheet of acellular dermal matrix (ADM) in a reproducible and elegant manner. The wrap design creates an anatomic tear-shaped pocket to guide expansion and encourage lower pole fullness, without ADM folding or bunching for optimal incorporation and minimal overlap. Further, it minimizes waste, allowing for smaller sheets of ADM to be used per breast, and can easily be performed in minimal time on the back table while the mastectomies are being performed, as a means of minimizing cost. Results: Our technique can be applied to effectively cover all shapes and sizes of expanders and implants, both teardrop and round. As a result, the surgeon need only focus on the critical nuances of prosthesis-based prepectoral breast reconstruction, without the anxiety of how to wrap the prosthesis and what size of ADM to use. Conclusions: The Butterfly Wrap is a simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral reconstruction.
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