Early Functional Outcomes After Prepectoral Breast Reconstruction: A Case-Matched Cohort Study

Comparative complications of prepectoral versus subpectoral breast reconstruction in patients with breast cancer: a meta-analysis

Introduction

This meta-analysis aims to evaluate the complications associated with prepectoral breast reconstruction (PBR) compared to subpectoral breast reconstruction (SBR) in patients diagnosed with breast cancer.

Materials and methods

A comprehensive search was performed in four databases, including Medline, Embase, Web of Science and CENTRAL, to collect literature published up until December 31, 2024. In addition, we conducted a thorough manual examination of the bibliographies of the identified papers, as well as pertinent reviews and meta-analyses. We conducted a search on three clinical trial registries, namely ClinicalTrials.gov, Controlled-trials.com, and Umin.ac.jp/ctr/index.htm. Meta-analyses were conducted on total complications, hematoma, infection, wound healing issues, necrosis, capsular contracture, rippling, animation deformity, and reoperation.

Results

A total of 40 studies were included in the meta-analysis. Compared with SBR, PBR significantly reduced the incidence of animated malformations (OR=0.37, 95% CI: 0.19 to 0.70, P=0.003, I ²=12%), but increased the incidence of ripples (OR=2.39, 95% CI: 1.53 to 3.72, P=0.0001, I ²=10%) and seroma (OR=1.55, 95% CI: 1.02 to 2.35, P=0.04, increasing I ²=70%).

Conclusions

Our findings indicate that PBR and SBR have comparable safety profiles, with similar total complication rates. Specifically, PBR is more likely to cause rippling and seroma, whereas SBR is more prone to causing animation deformity.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024565837, identifier CRD42024565837.

Modifiable Postmastectomy Radiation Therapy Factors and Impact on Implant-Based Breast Reconstruction Outcomes

BACKGROUND

Intensity-modulated radiation therapy and other modifiable radiation factors have been associated with decreased radiation toxicity. These factors could allow for improved reconstructive outcomes in patients requiring postmastectomy radiation therapy (PMRT). However, they have not yet been well studied in implant-based breast reconstruction.

METHODS

The authors performed a retrospective chart review of patients who underwent mastectomy with immediate tissue expander placement followed by PMRT. Radiation characteristics were collected, including radiation technique, bolus regimen, x-ray energy, fractionation, maximum radiation hot spot, and tissue volume receiving more than 105% or more than 107% of the prescription dose. Reconstructive complications occurring after initiation of PMRT were analyzed with respect to these radiation characteristics.

RESULTS

Sixty-eight patients (70 breasts) were included in this study. The overall complication rate was 28.6%, with infection being the most common complication (24.3%), requiring removal of the tissue expander or implant in greater than half of infections (15.7%). Maximum radiation hot spot was greater in patients who required explantation after PMRT, and this approached statistical significance (114.5% ± 7.2% versus 111.4% ± 4.4%; P = 0.059). Tissue volume receiving more than 105% and 107% were also greater in patients who required explantation after PMRT (42.1% ± 17.1% versus 33.0% ± 20.9% and 16.4% ± 14.5% versus 11.3% ± 14.6%, respectively); however, this was not statistically significant ( P = 0.176 and P = 0.313, respectively). There were no significant differences in complication rates between patients with respect to radiation technique or other radiation characteristics studied.

CONCLUSION

Minimizing the radiation hot spots and volumes of tissue receiving greater than the prescription dose of radiation may improve reconstructive outcomes in patients undergoing implant-based breast reconstruction followed by PMRT.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Predicting Final Implant Volume in Two-stage Prepectoral Breast Reconstruction

Two-stage implant-based breast reconstruction remains the most commonly performed reconstructive modality following mastectomy. Although prior studies have explored the relationship between tissue expander (TE) features and permanent implant (PI) size in subpectoral reconstruction, no such study exists in prepectoral reconstruction. This study aims to identify pertinent TE characteristics and evaluate their correlations with PI size for prepectoral implant-based reconstruction.

METHODS

This study analyzed patients who underwent two-stage prepectoral tissue expansion for breast reconstruction followed by implant placement. Patient demographics and oncologic characteristics were recorded. TE and PI features were evaluated. Significant predictors for PI volume were identified using linear and multivariate regression analyses.

RESULTS

We identified 177 patients and 296 breast reconstructions that met inclusion criteria. All reconstructions were performed in the prepectoral plane with the majority using acellular dermal matrix (93.8%) and primarily silicone implants (94.3%). Mean TE size was 485.4 cm³ with mean initial fill of 245.8 cm³ and mean final fill of 454.4 cm³. Mean PI size was 502.9 cm³ with a differential fill volume (PI-TE) of 11.7 cm³. Multivariate analysis identified significant features for PI size prediction, including TE size (R² = 0.60; P < 0.0001) and TE final fill volume (R² = 0.57; P < 0.0001). The prediction expression for TE final fill and TE size was calculated as 26.6 + 0.38*(TE final fill) + 0.61*(TE size).

CONCLUSIONS

TE size and final expansion volume were significant variables for implant size prediction. With prepectoral implant placement gaining popularity, the predictive formula may help optimize preoperative planning and decision-making in prepectoral reconstructions.

Advances in Prepectoral Breast Reconstruction

Breast reconstruction can be divided into prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR) according to the implant plane. The original prepectoral breast reconstruction was abandoned for a long time due to the frequent and severe complications. Now, advances in materials technology and improved methods of mastectomy have made safe prepectoral breast reconstruction possible. Moreover, a number of studies have gradually demonstrated the advantages of prepectoral breast reconstruction. As prepectoral breast reconstruction becomes more and more attractive, it is time to review the current advances in prepectoral 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.

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

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

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.

Drain Removal Time in Pre-pectoral versus Dual Plane Prosthetic Breast Reconstruction following Nipple-sparing Mastectomy

Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique.

Methods

A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.).

Results

The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days).

Conclusion

In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee

Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of prepectoral breast reconstruction. 2. Have knowledge of primary immediate and delayed prepectoral breast reconstruction techniques and secondary procedures required. 3. Describe data on outcomes of prepectoral breast reconstruction.

SUMMARY

Once considered to have an unacceptable complication profile, prepectoral breast reconstruction is increasing in popularity because of decreased surgical invasiveness and postoperative pain and the absence of animation deformity. Short-term outcomes studies comparing prepectoral breast reconstruction to partially submuscular techniques demonstrate similarly acceptable rates of postoperative complications. Aesthetic outcomes demonstrate similar rates of capsular contracture but increased rippling and implant palpability of the upper pole. Postoperative functional data are limited but overall show decreased pain and more rapid return of function but equivalent satisfaction on the BREAST-Q. Long-term aesthetic data and rates of revision are lacking.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction

Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.

Methods

To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.

Results

Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).

Conclusions

Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance

BACKGROUND

In the past decade, surgeons have increasingly advocated for a return to prepectoral breast reconstruction with claims that surgical mesh (including acellular dermal matrix) can reduce complication rates. However, numerous surgical and implant advancements have occurred in the decades since the initial prepectoral studies, and it is unclear whether mesh is solely responsible for the touted benefits.

METHODS

The authors conducted a systematic review of all English language articles reporting original data for prepectoral implant-based breast reconstruction. Articles presenting duplicate data were excluded. Complications were recorded and calculated on a per-breast basis and separated as mesh-assisted, no-mesh prior to 2006, and no-mesh after 2006 (date of first silicone gel-filled breast implant approval). Capsular contracture comparisons were adjusted for duration of follow-up.

RESULTS

A total of 58 articles were included encompassing 3120 patients from 1966 to 2019. The majority of the included studies were retrospective case series. Reported complication outcomes were variable, with no significant difference between groups in hematoma, infection, or explantation rates. Capsular contracture rates were higher in historical no-mesh cohorts, whereas seroma rates were higher in contemporary no-mesh cohorts.

CONCLUSIONS

Limited data exist to understand the benefits of surgical mesh devices in prepectoral breast reconstruction. Level I studies with an appropriate control group are needed to better understand the specific role of mesh for these procedures. Existing data are inconclusive but suggest that prepectoral breast reconstruction can be safely performed without surgical mesh.

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes

BACKGROUND

The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking.

METHODS

Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors.

RESULTS

Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis.

CONCLUSIONS

Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Assessment of Opioid-Prescribing Practices in Breast Augmentation: Future Directions for Prescribing Guidelines

BACKGROUND

The United States (US) is in the mid of an opioid epidemic propagated, in part, by prescription opioids. With excess overprescribing documented in a variety of surgical procedures, several societies have recommended opioid-prescribing guidelines. Considering the scope and postoperative pain associated with aesthetic plastic surgery procedures, earnest evaluation into opioid-prescribing practices for breast augmentation was conducted.

METHODS

Members of the American Society for Aesthetic Plastic Surgery were electronically surveyed on their opioid-prescribing patterns. The survey was distributed to 1709 plastic surgeons. Descriptive statistics were collated into percentages, deviations, and morphine milligram equivalents (MMEs), when appropriate.

RESULTS

Two hundred twenty-nine American Society for Aesthetic Plastic Surgery members (13.4%) provided responses. A total of 91.2% of respondents prescribe opioids to patients undergoing breast augmentation. The most commonly prescribed agents included oxycodone/acetaminophen (Percocet, 47.0%) and hydrocodone/acetaminophen (Vicodin, 38.3%). On average, 165.3 ± 81.7 MMEs were dispensed (range, 25.0-600.0 MMEs; number tablets, 5-60). Prescribers felt that a lack of phone-in prescribing (52.4%) and the ease of preemptively prescribing opioids (52.4%) propagate opioid overprescribing. A total of 61.3% of respondents reported that they are or may be in favor of developing plastic surgery societal guidelines related to opioid prescribing. These respondents indicated support for guidelines on opioid-sparing pain management strategies (74.2%) and guidelines identifying the type (54.7%), duration of use (69.5%), and number of opioid tablets (61.7%) necessary for procedures.

CONCLUSIONS

Considerable variability exists among prescribing patterns after breast augmentation. Societal guidelines aimed at providers and patients may serve a future role in opioid prescribing.

Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction

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.

Current Trends in Prepectoral Breast Reconstruction: A Survey of American Society of Plastic Surgeons Members

Prepectoral implant-based breast reconstruction has recently gained increasing popularity, but there are limited data regarding national trends in the use of this technique. Our aim was to determine practice patterns related to prepectoral breast reconstruction among plastic surgeons, as well as to identify perceived advantages and disadvantages of this technique.

Methods

A 16-question electronic survey tool was distributed to 2535 members of the American Society of Plastic Surgeons. Survey items focused on surgeon practices related to prepectoral reconstruction, in addition to their motivations for and concerns with performing the procedure.

Results

A total of 274 responses were received (10.8% response rate). Nearly half of respondents (48.4%) reported using prepectoral techniques in all or most of their procedures. Decreased animation deformity was identified as the most significant advantage by 76.3% of respondents. Increased rippling and potential wound healing complications were identified as the most significant disadvantages to the procedure by 49.1% and 40.4% of respondents, respectively. The majority of surgeons reported using acellular dermal matrices in their procedures, with most surgeons demonstrating preferences for cohesive and shaped devices.

Conclusions

Prepectoral breast reconstruction is being widely adopted by plastic surgeons, with the majority of surgeons in our sample using prepectoral techniques in their practices. Responses demonstrate that this technique offers several perceived advantages, most notably the avoidance of animation deformity. However, our data also highlight that there are still many unanswered questions in the community about the complication profile and technical aspects of prepectoral techniques that warrant further investigation.

Optimizing non-opioid pain control after implant-based breast reconstruction: a review of the literature and proposed pain control algorithm

Despite the intense focus on the opioid epidemic and its known association with surgical procedures, there is a paucity of evidence-based literature on pain management in implant-based breast reconstruction (IBR). Herein, we present an updated review of the literature aimed at identifying pain treatment protocols to minimize narcotic use and its associated potential addiction in IBR. A comprehensive review of the published English literature was conducted using Ovid Medline/PubMed Database without timeframe limitations. The inclusion criteria of selected articles presented in this review included studies reporting objective outcomes of pain modulation (preoperatively, intraoperatively and postoperatively) in IBR. Articles for inclusion were stratified based on intervention. A total of 219 articles were identified in the initial search query, with 23 studies meeting the inclusion criteria. Pain optimization interventions in IBR are herein summarized and analyzed based on the reported outcomes of each respective study. There is a substantial need for evidence-based guidelines in the plastic surgery literature for pain optimization without the use of opioids. While this review of studies to date investigates potential solutions, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized post-operative care for patients following IBR.

Surgical Outcomes in Prepectoral Breast Reconstruction

Background:

Prepectoral breast reconstruction has reemerged as a popular option for prosthetic-based breast reconstruction. Recent published literature highlights good outcomes; however, techniques are evolving and options exist for different technologies. The aim of this study is to evaluate short-term complication rates of prepectoral reconstructions using Cortiva acellular dermal matrix.

Methods:

A multicenter retrospective study was conducted of all patients who underwent mastectomy with immediate direct-to-implant or 2-stage prepectoral breast reconstruction with Cortiva (RTI Surgical, Alachua, Fla.) between January 2016 and September 2018. The incidence of surgical complications was determined and studied against patient demographics and procedural details.

Results:

One-hundred eighteen patients met the inclusion criteria for a total of 183 individual breasts reconstructed with prepectoral implant. Average length of follow-up was 9.26 months (range, 1.0 month to 2.5 years). Thirty-two breasts (17.49%) experienced 1 or more complications. Prepectoral reconstruction was successful 89.07% of the time. Infection was the most common cause of both reoperation and implant failure, with 7.65% of all breasts requiring washout and 5.46% failing prosthetic reconstruction secondary to infection.

Conclusions:

Surgical outcomes for prepectoral breast reconstruction using 2-stage and direct-to-implant are similar and comparable to the literature for dual-plane reconstruction, with infection being the main cause of failure.

Prepectoral breast reconstruction

Implant-based breast reconstruction is the most commonly used reconstruction technique after mastectomy. This is because skin-sparing mastectomy has become possible with advancements in oncology. In addition, the development of breast implants and the advent of acellular dermal matrices have reduced postoperative complications and resulted in superior cosmetic results. The most frequently performed surgical breast reconstruction procedure for the past 20 years was the insertion of an implant under the pectoralis major muscle by means of the dual plane approach. However, some patients suffered from pain and animation deformity caused by muscle manipulation. Recently, a prepectoral approach has been used to solve the above problems in select patients, and the results are similar to subpectoral results. However, this technique is not always chosen due to the number of considerations for successful surgery. In this article, we will discuss the emergence of prepectoral breast reconstruction, indications and contraindications, surgical procedures, and outcomes.

Comparison of prepectoral and subpectoral breast reconstruction after mastectomies: A systematic review and meta analysis

BACKGROUND

The safety of prepectoral breast reconstruction (PBR) after mastectomies as compared to subpectoral breast reconstruction (SBR) were unclear, so we conducted a systematic review to analyze their differences.

METHODS

PubMed, EMBASE, the Cochrane Library, and Web of Science databases were searched to retrieve studies that compared PBR with SBR after mastectomies. The outcomes were complications, oncological safety, patient-reported outcomes and postoperative pain. Revman software version 5.30 and stata vesion 12 was used to conduct meta-analysis where possible.

RESULTS

16 comparative studies (12 articles and four abstracts) were included. The meta analysis showed no statistical differences in overall complications, implant loss, seroma, nipple or skin flap necrosis, hematoma, reoperation, wound dehiscence, and wound-skin infection, rippling between PBR and SBR. PBR might be associated with fewer nipple or skin flap necrosis for those who received tissue expander placement, and fewer capsular contracture rates for those who received implant. PBR might be associated with better Breast Q scores and less postoperative pain without increasing the risk of local recurrence and metastatic disease.

CONCLUSION

Although available evidence is limited, PBR might be as safe as subpectoral approach. Future well designed multicenter randomized controlled trial that compare postmastectomy PBR with SBR is needed.