A Comparative Analysis between Subpectoral versus Prepectoral Single Stage Direct-to-Implant Breast Reconstruction

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method.

METHODS

PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes.

RESULTS

A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1).

CONCLUSIONS

While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.

ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a Meta-analysis

Implant-related breast reconstruction can be divided into subpectoral breast reconstruction (SPBR) and prepectoral breast reconstruction (PPBR) according to the different anatomical planes. The previous stereotype was that PPBR had a high complication rate and was not suitable for clinical use. However, with the emergence of acellular dermal matrix (ADM), the clinical effect of PPBR has been improved. To compare the outcomes difference between SPBR and PPBR, We conducted this meta-analysis. Articles on SPBR versus PPBR were searched in PubMed, Web of Sciences, Embase, and Cochrane databases, strictly following the PRISMA guidelines. According to the set criteria, we included the literature that met the requirements. Extracted data were the incidence of adverse events and the duration of drainage. Results show that SPBR has a higher incidence rate in capsular contracture, animation deformity, infection, hematoma and delayed healing wound than PPBR. There are no significant differences in skin flap necrosis, seroma, implant loss, reoperation and duration of drainage between the two groups. Hence, PPBR is no longer a high complication surgical method and can be used in the clinical practice. However, there are few large sample studies at present, so it is necessary to carry out further studies on PPBR.

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 .

The Language of Implant-based Breast Reconstruction: Can We Do Better?

The management of breast cancer has experienced tremendous changes in the last half-century. In today's multimodal approach to breast cancer, patients have the prospect of achieving a sense of normalcy after mastectomy thanks to advancements in oncology and breast reconstruction. Although the oncologic management of breast cancer has evolved over multiple centuries, implant-based breast reconstruction (IBBR) has only been around since the 1960s. The last half century has seen the conception of multiple techniques, novel devices, and new possibilities in hopes of achieving outcomes that are similar to or even better than the patient's premorbid state. However, with all these changes, a new problem has arisen-inconsistencies in the literature on how IBBR is described. In this article, we will discuss potential sources of confusion in the IBBR literature and lexicon, highlighting specific terms that may have multiple meanings or interpretations depending on perspective, context, and/or intent. As a first step toward clarifying what we perceive as a muddied landscape, we propose a naming convention for IBBR that centers around four important variables especially pertinent to IBBR-the type of mastectomy performed, the timing of reconstruction, the type of device that is placed, and the pocket location for device placement. We believe that adoption of a more standardized, consistent, and descriptive lexicon for IBBR will help provide clearer communication and easier comparisons in the literature so that we may continue to deliver the best outcomes for our patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

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

Methods

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

Results

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

Conclusions

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

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.

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.

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.

Capsular Contracture in Breast Implant Surgery: Where Are We Now and Where Are We Going?

Capsular contracture is the leading complication after surgery with breast implants. A lot of progress has been made investigating this complication over the years, and knowledge has been gained on this complication. Currently, the exact cause for capsular contracture is still unclear. It has been hypothesized that immunobiological factors (i.e., immunological and bacterial factors) and several risk factors play a central role in its development. In this paper, we give an overview of the known immunological factors that have been investigated in contracted and non-contracted capsules, as well as the role of bacterial formation around breast implants. We also report on risk factors that might increase the risk of capsular development. Lastly, it provides the latest research on this matter and discusses future perspectives as follow-up research is needed to unravel the pathogenic process leading to capsular contracture. This knowledge is of interest to establish medical therapies in order to prevent such side effects. Overall, capsular contracture seems to be a multifactorial condition consisting of several risk factors. 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 .