Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience

Abstract

Background The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dualplane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates. Materials and Methods A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retropectoral muscular position ? ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded. Results We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were prepectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma. Conclusion Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries.

Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction: Preliminary Results

“…Over the years, different techniques have been introduced in order to improve aesthetic and functional results in breast reconstruction. The use of prosthetic breast reconstruction has risen significantly, becoming the most frequent choice [20,21].…”

Short- to Medium-term Outcome of Prepectoral versus Subpectoral Direct-to-implant Reconstruction using Acellular Dermal Matrix

“…A multicenter large study reported by Ribuffo et al comparing prepectoral (207 breasts) and subpectoral reconstruction (509 breasts) with ADM reported overall complication significantly higher in the subpectoral group mainly attributed to seroma and hematoma formation and animation deformity, which were significantly higher in the subpectoral group. 23 Incidence of wound dehiscence was 1.9% in the prepectoral group and 2.5% in the subpectoral group, which was not statistically significant. All patients in the above study had a minimum follow-up of 1 year, and the incidence of implant loss was 2.4% in the prepectoral group compared with 3.9% in the subpectoral group, which was not statistically significant.…”

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

“…29 This could activate innate immunity at the implant interface more than muscle and would be consistent with the increased capsular contracture rate observed in subglandular breast augmentation. 3,5,30 Collectively, these data all suggest that the adjacent tissue type could locally direct periprosthetic inflammation, which could in turn explain the difference in capsular contracture observed clinically based on implant insertion plane.…”

“…4,6 In contrast, during breast reconstruction submuscular implant poses a greater risk of capsular contracture, affecting up to 8.7% of patients with prepectoral reconstruction with ADM and up to 13.9% of patients with subpectoral reconstruction. 5,6 Intraoperative maneuvers and manipulation of the breast implant can also reduce the risk of capsular contracture by utilizing the "14-point plan. [55][56][57] Steps 1 to 7 have already been described, and they include administering proper prophylactic antibiotics, avoiding periareolar incisions, using nipple shields, atraumatic dissection of a subpectoral pocket, meticulous hemostasis, and utilization of a triple antibiotic solution on the implant and breast pocket.…”

“…2 In breast augmentation, capsular contracture affects 1.9% of patients with submuscular implants and 9.6% of patients with subglandular implants; in breast reconstruction capsular contracture affects up to 8.7% of patients with prepectoral reconstruction with acellular dermal matrix (ADM) and up to 13.9% of patients with subpectoral implants. [3][4][5][6][7] These numbers increase substantially in radiated patients, with up to 40% of patients receiving post-mastectomy radiotherapy suffering from capsular contracture. 3 Despite the high incidence of capsular contracture, an effective treatment remains elusive with up to 54% of surgically managed capsular contracture cases recurring.…”