Correction of animation deformity with subpectoral to prepectoral implant exchange

Abstract

Background: Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. Methods: We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Results: Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Conclusions: Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

Prepectoral implant pocket conversion in breast reconstruction

“… 18 Among the ten selected articles, seven were retrospective studies 22 , 23 , 24 , 25. , 26 , 28 , 30 and three were prospective studies. 21 , 27 , 29 A total of 504 breasts were included in the review and the sample size of each article ranged from 8 to 142 breasts.…”

“…The main indication to implant pocket conversion was the appearance of AD. Chronic pain and implant malposition represented the other two indications mentioned respectively in six 24 , 25 , 27 , 28 , 29 and three articles. 23 , 26 , 27…”

“…Five studies described complete capsulectomy 21 , 23 , 28 , 30 and two studies described partial capsulectomy 22 , 25 , 29 ( Figure 2 ). Hammond et al.…”

“…All of the studies reported the use of ADMs except for three studies in which a part of the sample underwent pocket conversion without ADMs (29 patients). 24 – 28 , 30 The majority of the authors reported anterior implant coverage, while three authors 28 – 30 described complete anterior and posterior coverage using one or two sheets of human-derived ADMs (Alloderm) or a single sheet of bovine-derived ADM (Braxon; Decomed Srl) ( Figure 3 ). Sbitany 21 used an ADM as a lower pole hammock and an upper pole spacer between the PM and the mastectomy skin flap.…”

Delayed acellular dermal matrix assisted prepectoral breast reconstruction: Preliminary results

“…A series of 10 patients undergoing pocket change using human ADM to treat muscular distortion has been published by Hammond and reports a complete resolution of the animation deformity . Similarly, Lentz and Gabriel presented two retrospective series of 31 and 102 patients who underwent prepectoral revision reconstruction using human ADM and fat graft, with optimal aesthetic results and complete resolution of animation deformity . Anyway, these previous studies described different techniques of human ADM insetting (frontal inferior with or without frontal superior coverage, total frontal coverage, frontal coverage with partial posterior coverage) depending on patient preoperative situation.…”