Dual-Plane versus Prepectoral Breast Reconstruction in High-Body Mass Index Patients.

BACKGROUND: Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m) is technically challenging and is associated with increased postoperative complications. The optimal reconstructive approach for these patients remains to be determined. This study compared outcomes of prepectoral and dual-plane reconstruction in high-BMI patients to determine whether there was an association between postoperative complications and the plane of reconstruction. METHODS: High-BMI patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction were included in this retrospective study. Patients were stratified by reconstructive approach (dual-plane or prepectoral), and postoperative complications were compared between the groups. Multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was an independent predictor of any complication after adjusting for potential confounding differences in patient variables between the groups. RESULTS: Of 133 patients, 65 (128 breasts) underwent dual-plane and 68 (129 breasts) underwent prepectoral reconstruction. Rates of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) were significantly higher in patients who had dual-plane versus prepectoral reconstruction (p < 0.05). Multivariate logistic regression identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication (p < 0.05). Dual-plane reconstruction increased the odds of any complication by 3-fold compared with the prepectoral plane. CONCLUSION: Compared with the dual-plane approach, the prepectoral approach appears to be associated with a lower risk of postoperative complications following immediate expander/implant breast reconstruction and may be a better reconstructive option in high-BMI patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effect of Body Mass Index on Outcomes after Prepectoral Breast Reconstruction.

BACKGROUND: Body mass index has been shown to be a predictor of outcomes after subpectoral expander/implant reconstruction, with every unit increase in body mass index increasing the risk of complications by approximately 6 percent. The effect of body mass index on complications after prepectoral reconstruction has not yet been evaluated and is the purpose of this study. METHODS: A total of 366 reconstructed breasts from 197 patients were stratified into five body mass index groups (normal; overweight; and class I, class II, and class III, obese) and postoperative complications were compared across the groups. Additional analyses were performed using broad classifications of body mass index into nonobese and obese in addition to normal, overweight, and obese. Body mass index as an independent predictor of complications was assessed using multivariate logistic regression analysis. RESULTS: Complication rates did not differ significantly across body mass index groups when using the broad classifications. With five-group stratification, significantly higher rates of return to operating room, expander/implant loss, skin necrosis, wound dehiscence, and overall complications were seen in class II and/or class III obese versus overweight patients. However, on multivariate logistic regression analyses, body mass index, as a continuous variable, did not independently predict any complication. Diabetes and smoking emerged as significant predictors of any complication, indicating that these factors, rather than body mass index, were driving the increased rates of complications seen in the high-body mass index groups. CONCLUSION: Body mass index alone is not a predictor of outcomes after prepectoral expander/implant breast reconstruction and should not be used to estimate risk of postoperative complications or exclude patients for prepectoral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The breast surgeons' approach to mastectomy and prepectoral breast reconstruction.

The purpose of this review article is to discuss and highlight the data, techniques and our experience performing mastectomies in the setting of prepectoral breast reconstruction. Using a systematic review of the approach to mastectomy in the oncologic setting encompassing patient selection, safety, anatomy and methods including a literature review of mastectomy trends, safety data and outcomes, anatomy and our experience, we are able to illustrate the safety and utility of this technique. The literature strongly supports the oncologic safety of these methods. This review also supports the use of these techniques as a surgical approach to any mastectomy, with or without reconstruction, and addresses many of the factors involved in improving and maximizing outcomes. While, there are multiple and equally efficacious approaches to mastectomy, several surgical techniques can be used to improve outcomes and ensure optimal flap viability.

Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions.

BACKGROUND: Animation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Moving the implant from subpectoral to prepectoral has the potential to eliminate animation deformity. OBJECTIVES: Describe the technique and outcomes of prepectoral revision reconstruction in over 100 cases and discuss patient selection criteria for a successful outcome. METHODS: Patients who presented with animation deformity following two-stage implant reconstruction were included in this retrospective study. Revision surgery involved removal of the existing implant via the previous incision site along the inframammary fold, suturing of the pectoralis major muscle back to the chest wall, creation of a prepectoral pocket for the new implant, use of acellular dermal matrix to reinforce the prepectoral pocket and completely cover the implant, and fat grafting to enhance soft tissue. Patients were evaluated for resolution of animation deformity and occurrence of complications during follow up. RESULTS: Fifty-seven patients (102 breasts) underwent prepectoral revision reconstruction with complete resolution of animation deformity. Complications occurred in 4 breasts (3.9%) and included seroma (2 breasts), skin necrosis (3 breasts), and wound dehiscence (1 breast). All 4 breasts with complications had their implants removed and replaced. There were no incidences of infection or clinically significant capsular contracture in this series. CONCLUSIONS: Revision reconstruction with prepectoral implant placement and complete coverage with acellular dermal matrix resolves animation deformity and results in aesthetically pleasing soft breasts. Patient selection is critical for the success of this technique.

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results.

Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prepectoral Implant-Based Breast Reconstruction and Postmastectomy Radiotherapy: Short-Term Outcomes.

BACKGROUND: Prosthetic breast reconstruction in the setting of radiotherapy is associated with poor outcomes. Until recently, prosthetic breast reconstruction was predominantly performed by placing the prosthesis in a subpectoral space. Placement of the prosthesis in a prepectoral space is currently emerging as a simpler, alternative approach to subpectoral placement. The impact of postmastectomy radiotherapy (PMRT) on prepectoral reconstruction has not yet been specifically assessed. This study compared the outcomes of patients who underwent immediate, direct-to-implant, or 2-staged, prepectoral breast reconstruction followed by PMRT with those from patients who did not receive PMRT. METHODS: Patients with well-perfused skin flaps and without contraindications, including uncontrolled diabetes-mellitus, previous irradiation, and current tobacco use, were offered the prepectoral approach. Following implant or expander placement, patients underwent planned or unplanned radiotherapy. Complications after each stage of reconstruction were recorded. RESULTS: Thirty-three patients underwent 52 breast reconstructions via the prepectoral approach. Sixty-five percentage of the breasts were irradiated, including 21% after expander and 44% after implant placement. Patients were followed for a mean of 25.1 ± 6.4 months. Complication rate in irradiated breasts was 5.9% (1 incidence of seroma and 1 incidence of wound dehiscence followed by expander removal) and 0% in nonirradiated breasts. Capsular contracture rate was 0% in both irradiated and nonirradiated breasts. CONCLUSIONS: Immediate implant-based prepectoral breast reconstruction followed by PMRT appears to be well tolerated, with no excess risk of adverse outcomes, at least in the short term. Longer follow-up is needed to better understand the risk of PMRT in prepectorally reconstructed breasts.