Background: The aim of this study was to compare outcomes of immediate prosthetic breast reconstruction (IPBR) using traditional submuscular (SM) positioning of implants versus prepectoral (PP) positioning of micropolyurethane-foam-coated implants (microthane) without further coverage. Methods: We retrospectively reviewed the medical records of breast cancer patients treated by nipple-sparing mastectomy (NSM) and IPBR in our institution during the two-year period from January 2018 to December 2019. Patients were divided into two groups based on the plane of implant placement: SM versus PP. Results: 177 patients who received IPBR after NSM were included in the study; implants were positioned in a SM plane in 95 patients and in a PP plane in 82 patients. The two cohorts were similar for mean age (44 years and 47 years in the SM and PP groups, respectively) and follow-up (20 months and 16 months, respectively). The mean operative time was 70 min shorter in the PP group. No significant differences were observed in length of hospital stay or overall major complication rates. Statistically significant advantages were observed in the PP group in terms of aesthetic results, chronic pain, shoulder dysfunction, and skin sensibility (p < 0.05), as well as a trend of better outcomes for sports activity and sexual/relationship life. Cost analysis revealed that PP-IPBR was also economically advantageous over SM-IPBR. Conclusions: Our preliminary experience seems to confirm that PP positioning of a polyurethane-coated implant is a safe, reliable and effective method to perform IPBR after NSM.

The appearance of coronavirus disease 2019 (COVID-19) has provoked a global public health emergency, spreading to more than 150 countries, 1 and Italy has been particularly affected.The COVID-19 pandemic has represented a contemporary "sui generis" challenge for healthy system requiring a sudden reorganization of hospital structures and resettlement of therapeutic algorithms. The directives of the Italian Ministry of Health indicated to postpone all nonurgent surgical procedures and outpatient services, performing only urgent interventions or procedures for oncological pathologies. On March, the American College of Surgeons published guidelines for triage of nonemergent surgical intervention during the coronavirus pandemic, based on the Elective Surgery Acuity Scale (ESAS). 2 The ESAS considers lowrisk cancer as tier 2a (deferrable whenever possible) and other cancers as tier 3 a and so not deferrable. 2 Cancer patients have an elevated risk for acquiring COVID-19 and subsequent complications because of their immunodepression, poor functional status, and frequent hospital visits and admissions. 3 Moreover, Liang et al reported that oncologic patients who underwent surgery in the 30 days before contracting COVID-19 in China developed more frequently a severe form of disease compared to those who did not underwent surgery. 4 Breast carcinoma is the most frequent malignancy among women, and its modern surgical treatment nowadays includes breast reconstruction. Given the rapid evolution of the current situation, very few data of the different breast units about the present attitude toward breast cancer management are available. 5 Breast surgeons seem to agree on the fact that delaying elective surgical procedures may be more appropriate for select cases such as clinical stage I or stage II in which 60-day delays in surgical intervention were not associated with worse oncological outcomes. 6,7 To date, no guidelines on breast reconstructive surgery have been published. The aim of this article is to report our decision-making attitude during COVID-19 emergency in the field of breast reconstruction. In line with government directives, our institution limits elective surgery to oncologic procedures, and the reconstructive time is considered an integrated part of the treatment. All admitted patients undergo a pharyngeal swab at time of hospitalization. Our breast unit delays surgical treatment for low-grade tumors and ductal carcinoma in situ, while other breast cancer patients are offered lumpectomy or mastectomy as needed. Patients are evaluated case by case by a multidisciplinary team composed by breast surgeon, oncologist, radiologist and plastic surgeon to minimize the exposure to COVID-19 without compromising oncological safety and offering the best possible aesthetic outcome. The plastic surgeon purpose should be to achieve a satisfactory aesthetic result by adopting the easiest technique, limiting as much as possible operating times, risk of postoperative complication, duration of hospitalization, and outpatient v...

Immediate prepectoral breast reconstruction after conservative mastectomy had a widespread diffusion in the last years. 1,2 In our opinion, the indications to the prepectoral implant placement should not be limited to the immediate reconstruction but can be extended to some cases of delayed reconstruction. This article portrays our series of delayed acellular dermal matrix (ADM)-assisted prepectoral reconstruction using preshaped porcine-derived Braxon (Decomed Srl).A prospective study was conducted among patients who underwent delayed ADM-assisted (Braxon) prepectoral reconstruction from January 2017 to December 2018. Patients included had a previous (>1 year before) mastectomy with submuscular implants or tissue expander (TE) reconstruction and presented one or more of the following complications: severe animation deformity, alteration of shape, implant malposition, dysfunctional chronic chest pain, submuscular implant loss after infection.In case of pinch test >3 cm at the upper pole and >1 cm at the lower pole, the patient was considered a good candidate to conversion; in case of pinch test >1.5 cm <3 cm at the upper pole and >1 cm at the lower pole one or more preparatory fat grafts were performed before the implant position conversion. Patients with pinch test <1.5 cm at the upper pole were excluded.A distinguishing group of patients suitable for prepectoral delayed reconstruction includes those needing delayed reconstruction after nipple sparing mastectomy (NSM) and submuscular TE with previous contralateral breast reconstruction with autologous tissues, and impossibility for clinical, intraoperative, or psychological reasons to perform a second free or local flap. Patient's satisfaction was measured using BreastQ ["satisfaction with breast"-"satisfaction with outcome" domains]. Implant pocket was accessed through the previous scar and the plane over the anterior capsule was undermined. The pectoralis major (PM) was then dissected from the overlying subcutaneous tissue recreating a new pocket. After implant removal, anterior or subtotal capsulectomy was performed. The inferior border of the PM was anchored to the posterior capsule or the chest wall (Figure 1). Total implant coverage with Braxon was prepared. The ADM implant was placed in the new prepectoral space and anchored to the muscle using cardinal sutures (3,6,9, and 12-clock positions) with 2/0 vicryl sutures. Tissue glue (Evicel) was sprayed, or supplementary stitches were placed between the ADM and subcutaneous layer. A total of 20 breast in 13 patients (7 bilateral, 6 unilateral reconstructions) with a mean age of 50.8 years (33-59) were selected for delayed total coverage ADM-assisted prepectoral breast reconstruction. Two patients (4 breasts) presented an animation deformity complicated by chronic pain in 1 case. Four patients (8 breasts) presented an implant malposition with an alteration of shape (Figure 2). Two patients (3 breasts) had a surgical history of implant loss after infection and underwent 3 sessions of fat grafting before the con...