Prepectoral breast reconstruction with complete anterior implant coverage using a single, large, square-shaped acellular dermal matrix

Abstract

Background Several studies have discussed various methods of prepectoral direct-to-implant (DTI) breast reconstruction using an acellular dermal matrix (ADM) prosthesis to achieve full coverage. However, methods for anterior coverage have rarely been reported. In this study, prepectoral DTI breast reconstruction with complete anterior implant coverage was performed using a square piece of ADM. This study aimed to introduce our prepectoral DTI technique and determine its functional and cosmetic outcomes as well as compare them with those of existing subpectoral DTI techniques. Methods This prospective comparative study focused on 29 patients (35 breasts) and 34 patients (35 breasts) who underwent breast reconstruction via subpectoral implant insertion (control group) and anterior coverage prepectoral implant insertion (anterior coverage group), respectively. Postoperative complications were noted, and breast symmetry was evaluated using the Vectra H2 three-dimensional scanner. The modified Kyungpook National University Hospital Breast-Q (KNUH Breast-Q) scale was used to assess the patient’s subjective satisfaction with the reconstruction and postoperative quality of life. Results No remarkable differences in terms of complications (seroma, skin necrosis, nipple–areola complex necrosis, hematoma, capsular contracture, and infection) were noted in both groups. Compared with controls, considerably better results were observed among those in the anterior coverage group in terms of the mean drain removal period. Furthermore, those in the anterior coverage group showed greater symmetry on three-dimensional scans than the controls; however, this was not statistically significant. Subjective satisfaction and postoperative quality of life measured using the KNUH Breast-Q scale were not significantly different between both groups. Conclusions Considering its stability, faster recovery time, and cosmetic benefit, prepectoral breast reconstruction with anterior implant coverage using a single, large ADM is a good choice to perform breast reconstruction with implant insertion in patients who have undergone mastectomy. Level of evidence: II.

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction

“…Eighteen studies reported postoperative infection rates 3,4,11–26 . Overall, the rate of surgical site infections was 2.6% (n = 35/1369) and 4.1% (n = 73/1767) after prepectoral and subpectoral implants, respectively.…”

“…In addition, it is worth noting that the definition of surgical revision varies in each study. While most studies only considered unexpected or salvage reoperation as reintervention (Mirhaidari et al, 21 Hong et al 15 ), some studies included fat grafting as reintervention (Manrique et al, 3 Bernini et al 12 ) and others included revision for aesthetic concerns as reintervention (Antony et al, 11 Nealon et al 23 ). While some might argue that fat grafting should not be considered a complication, we believe that fat grafting should be counted as a reintervention as every additional procedure after index procedure confers risk for patients.…”

“…Sixteen studies reported postoperative seroma rates. 3,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Overall, the rate of seroma was 5.0% (n = 62/1228) and 8.6% (n = 135/1572) after prepectoral and subpectoral reconstruction, respectively. Our pooled analysis found that prepectoral reconstruction was associated with a significant decrease in odds for developing seroma (OR, 0.67; 95% CI, 0.48-0.92; P = 0.01; Fig.…”

“…Fifteen studies reported postoperative hematoma. 3,[11][12][13][15][16][17][18][20][21][22][23][24][25][26] Overall, the rate of hematoma was 2.1% (n = 25/1207) and 3.5% (n = 56/ 1580) after prepectoral and subpectoral implant reconstruction, respectively. The lower hematoma rates among prepectoral implant patients led to slightly lower odds for developing hematoma (OR, 0.62; 95% CI, 0.39-0.99; P = 0.05; Fig.…”

“…Six studies from the United States, 3 studies from Korea, and 4 studies from Italy reported postoperative seroma. 3,[11][12][13][15][16][17][18][19][21][22][23]25 Our subgroup analysis revealed that Italy had a significantly lower odd of developing a seroma in the prepectoral reconstructive group compared with the United States and Korea (Italy: OR, 0.45; 95% CI, 0.26-0.79; P = 0.005; United States: OR, 1.03; 95% CI, 0.60-1.75; P = 0.92; Korea: OR, 0.82; 95% CI, 0. 38-1.78, P = 0.62; Fig.…”