The role of fat grafting in prepectoral breast reconstruction

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

Background and Objective

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

Methods

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

Key Content and Findings

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

Conclusions

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE V

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

Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis

BACKGROUND

Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients.

METHODS

A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting.

CONCLUSIONS

In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.

Literature review and guide for optimal position in implant-based breast reconstruction

Background and Objective

Identification of ideal candidates for prepectoral versus retropectoral implant-based breast reconstruction relies on careful preoperative risk assessment and intraoperative flap evaluation. Few guidelines exist to guide the surgeon's decision-making process when evaluating the preferred plane for implant placement.

Methods

A literature review was performed to develop clinical decision-making algorithms for direct-to-implant (DTI) reconstruction with acellular dermal matrix (ADM) for patients undergoing prophylactic or therapeutic nipple-sparing mastectomy (NSM) based on patient characteristics, surgical techniques, and outcomes.

Key Content and Findings

Prepectoral reconstruction is most suitable for patients with small breasts or macromastia with desire for breast reduction, low-grade ptosis, smaller implant sizes, those undergoing PMRT, and for those who aim to mitigate animation deformity and capsular contracture. Retropectoral reconstruction may be recommended for patients with larger breasts with no desire for size change requiring additional prosthesis support, and in patients who aim to reduce likelihood of rippling and need for subsequent fat grafting procedures to address contour abnormalities.

Conclusions

Careful preoperative and intraoperative assessment of reconstruction options for patients undergoing implant-based breast reconstruction is necessary to mitigate complications and produce superior aesthetic outcomes. Decision algorithms may be used to determine ideal surgical techniques based on patient factors, like radiation history and planning, breast size and ptosis, and patient preferences.

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

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

Red Breast Syndrome and Acellular Dermal Matrix

Increasingly popular for use in breast reconstruction, acellular dermal matrix (ADM) can provide support and protection to implants. However, use of ADM may be associated with infection and complications, including red breast syndrome (RBS). RBS is an inflammatory event that typically presents with cutaneous erythema over the domain where the ADM is surgically implanted. As ADM use increases, presumably, more cases of RBS will occur. Thus, techniques and tools to mitigate or manage RBS are needed to improve patient outcomes. Here, we describe a case where RBS was diagnosed and interestingly resolved after exchange for a different brand of dermal matrix. This surgical resolution maintained excellent reconstructive results with no recurrent erythema over a follow-up period of 7 months. Although we cannot rule out RBS due to other variables, RBS due to patient hypersensitivity to certain ADMs has been documented in the literature. In this instance, our results suggest that revision with an alternate ADM brand may serve as a potential solution.

Postoperative Complications Following Prepectoral Versus Partial Subpectoral Implant-Based Breast Reconstruction Using ADM: A Systematic Review and Meta-analysis

BACKGROUND

There is a paucity of evidence comparing the safety of prepectoral and partial subpectoral implant-based breast reconstruction using acellular dermal matrices (ADM). We performed a meta-analysis to evaluate the postoperative complications of the two approaches.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The rates of the complications were, respectively, pooled, and relative risk (RR) was estimated with 95% confidence intervals (CIs) to compare the incidence between the two cohorts.

RESULTS

Ten articles reporting on 2667 breast reconstructions were eligible. The hematoma rate was lower in the prepectoral group (RR  =  0.590, 95% CI 0.351-0.992). No significant difference was observed in terms of seroma (RR = 1.079, 95% CI 0.489-2.381), skin flap necrosis (RR = 0.936, 95% CI 0.587-1.493), infection (RR = 0.985, 95% CI 0.706-1.375), tissue expander/implant explantation (RR  =  0.741, 95% CI 0.506-1.085), wound dehiscence (RR = 1.272, 95% CI 0.605-2.673), capsular contracture (RR = 0.939, 95% CI 0.678-1.300) and rippling (RR = 2.485, 95% CI 0.986-6.261). The RR of animation deformity for the prepectoral group compared with the subpectoral group was 0.040 (95% CI, 0.002-0.853).

CONCLUSIONS

This systematic review suggested that with appropriate patient selection, prepectoral breast reconstruction could avoid animation deformity without incurring higher risk of early wound complications, capsular contracture or rippling than partial subpectoral breast reconstruction. Plastic surgeons should complete a comprehensive assessment of the patients before choosing appropriate surgical approaches in clinical practice.

LEVEL OF EVIDENCE III

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

Optimizing Prepectoral Implant Placement and Concomitant Fat Grafting After Tissue Expansion

BACKGROUND

Prepectoral implant-based breast reconstruction is often supplemented by autologous fat grafting to optimize aesthetic outcomes. This usually entails several rounds of modest fat transfer to minimize risk of necrosis; however, the limits of fat grafting at expander exchange are not known.

METHODS

A single-institution retrospective review from July 2016 to February 2022 was performed of all patients who underwent (1) mastectomy, (2) prepectoral tissue expander placement, (3) expander exchange for implant, and (4) at least one round of autologous fat transfer. Student t test and χ2 test were used.

RESULTS

A total of 82 breasts underwent a single round of fat grafting during implant placement (group 1); 75 breasts underwent fat grafting that occurred in multiple rounds and/or in delay to implant placement (group 2). Group 1 received more fat at the time of implant placement (100 mL; interquartile range, 55-140 mL; P < 0.001) and underwent fewer planned operative procedures compared with group 2 (1.0 vs 2.2, P < 0.001). Total fat volume in group 2 did not significantly exceed that of group 1 until after 3 rounds of fat transfer (128.5 mL; interquartile range, 90-130 mL; P < 0.01). There was no difference in the rate of fat necrosis between groups after the first round (15.9% vs 9.3%, P = 0.2) and final round (15.9% vs 12.0%, P = 0.5) of fat grafting. Complication rates were similar between groups (3.7% vs 8.0%, P = 0.2).

CONCLUSIONS

A 2-stage approach of prepectoral tissue expander placement with single round of larger volume fat transfer at expander exchange reduces overall number of operative procedures without increased risks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

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

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.

Cost analysis of pre-pectoral implant-based breast reconstruction

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

Review of Autologous Fat Grafting in Postmastectomy Reconstruction Patients: Nonroutine Diagnostics and Oncologic Safety

Autologous fat grafting (FG) is increasingly used as an adjunctive reconstruction technique to augment volume, achieve symmetry, and improve contour deformities. This study aims to characterize the oncologic and surgical safety of FG in women undergoing autologous breast reconstruction (ABR) or implant-based reconstruction (IBR).

METHODS

A retrospective chart review was performed for all patients undergoing FG at a multi-site single health system between 2015 to 2018. A total of 228 eligible breasts from 155 patients were identified using Current Procedural Terminology codes. Patients were divided by reconstructive technique. Bivariate analyses compared baseline characteristics and post-FG outcomes.

RESULTS

Mean age for patients undergoing ABR (129 breasts) was 52.8 years compared to 48.6 years for those undergoing IBR (99 breasts; P = 0.002). A heavier volume of fat was grafted per ABR breast (143.8mL) than per IBR breast (102.2mL; P = 0.002). Forty-seven (20.6%) breasts required FG revision, more frequently in ABR breasts (31.0%) than IBR breasts (7.1%; P < 0.001). Following FG, 17.5% of patients experienced a palpable mass, and 18.9% of breasts underwent nonroutine diagnostics or procedures, with no difference between ABR and IBR groups. Most biopsies noted benign findings such as fat necrosis (2.2%) or a benign mass (0.9%), with recurrence only noted in two patients (0.9%). Mean follow-up was 20.4 months.

CONCLUSION

FG is a safe, surgically simple procedure more commonly performed in ABR breasts. FG use in ABR and IBR breasts is oncologically safe, with no impairment in breast surveillance and low rates of locoregional recurrence, but possibly increased incidence of nonroutine imaging and biopsies.

Prepectoral Breast Reconstruction without Acellular Dermal Matrix: Have We Come Full Circle?

Breast reconstruction is an integral part of breast cancer treatment [...].

Nipple-sparing Mastectomy: What the Radiologist Should Know

Nipple-sparing mastectomy (NSM) is increasingly offered to patients undergoing treatment of breast cancer and prophylaxis treatment for reduction of breast cancer risk. NSM is considered oncologically safe for appropriately selected patients and is associated with improved cosmetic outcomes and quality of life. Accepted indications for NSM have expanded in recent years, and currently only inflammatory breast cancer or malignancy involving the nipple is considered an absolute contraindication. Neoplasms close to and involving the nipple areolar complex are common, and cancer of the lactiferous ducts can spread to the nipple. Therefore, accurate determination of nipple involvement at imaging examinations is critical to identifying appropriate candidates for NSM and preventing local recurrence. Multiple imaging features have been described as predictors of nipple involvement, with tumor to nipple distance, enhancement between the index malignancy and the nipple, and nipple retraction demonstrating the highest predictive values. These features can be assessed at multimodality breast imaging, particularly at breast MRI, which demonstrates high specificity and negative predictive value for determining nipple involvement in malignancy. Online supplemental material is available for this article. ^©RSNA, 2022.

A systematic review and meta-analysis on the prepectoral single-stage breast reconstruction

BACKGROUND

The use of acellular dermal matrices (ADMs) and mesh reopened the possibility for the prepectoral single-stage breast reconstruction (PBR). The complications of single-stage breast reconstruction after PRB are controversial. We conducted a systematic review and meta-analysis of the impact of implant plane on single-stage breast reconstruction. Our aim was to evaluate the different postoperative complications between patients receiving prepectoral breast reconstruction and subpectoral breast reconstruction (SBR) on single-stage breast reconstruction.

METHODS

A comprehensive research on databases including PubMed, Embase, and Cochrane libraries was performed to retrieve literature evaluating the effect of implant plane on single-stage breast reconstruction from 2010 to 2020. All included studies were evaluated the complications after single-stage breast reconstruction. Only studies comparing patients who underwent prepectoral reconstruction with a control group who underwent subpectoral reconstruction were included.

RESULTS

A total of 13 studies were included in the meta-analysis, with a total of 1724 patients. In general, compared with SBR group, the PBR significantly reduced the risk of total complications (including seroma, hematoma, necrosis, wound dehiscence, infection, capsular contraction, implant loss/remove, and rippling) after single-stage breast reconstruction (OR: 0.54, 95% CI: 0.44-0.67, p < 0.001). Compared with the SBR group, the PBR had remarkably decreased capsular contracture (OR: 0.40, 95% CI: 0.27-0.58, p < 0.001) and postoperative infection (OR: 0.58, 95% CI: 0.36-0.95, p = 0.03).

CONCLUSION

The PBR is a safe single-stage breast reconstruction with fewer postoperative complications. It is an alternative surgical method for SBR.

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.

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction

INTRODUCTION

Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions.

METHODS

Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions.

RESULTS

Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034).

CONCLUSIONS

Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

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.

Fat Grafting in Breast Reconstruction

The past two decades have witnessed a growing application of autologous fat grafting in the setting of breast reconstruction after surgical treatment of breast cancer. While traditionally used to correct contour deformities during secondary revisions, fat grafting has since evolved to achieve desired breast shape and size both as a complementary adjunct to established reconstructive techniques as well as a standalone technique for whole breast reconstruction. In this article, we will review fat grafting as an adjunct to autologous and implant-breast based reconstruction, an option for primary breast reconstruction, and a treatment of postmastectomy pain.

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.