Prepectoral Prosthetic Breast Reconstruction Without ADM Using a Subfascial Approach

Abstract

Background Immediate prosthetic reconstruction has evolved to a prepectoral position. A technique is described where the pectoral and serratus fascia is raised from superiorly. Initially, Vicryl mesh was used to close the superior fascial defect, but later abandoned by using primary closure for tissue expanders, or creating a pocket in the infraclavicular pectoralis muscle after prosthesis (DTI) insertion. The inframammary fold is also reinforced. Patients with a BMI > 30 have axillary liposuction. Method Retrospective analysis over a 4-year period. Data included age, number of breasts having expanders or DTI. Prosthetic extrusion and follow-up were recorded. The percentage coverage by fascia was calculated. Results Forty-seven patients (80 breasts) had mean age of 42 years (range 32–62), twelve patients (19 breasts) had Vicryl mesh inserted, while 35 patients (61 breasts) had closure as noted above. Tissue expanders were inserted in 39 breasts (10 mesh, 29 without). DTI (direct to implant) performed in 41 breasts (32 no mesh, 9 with mesh). Three patients with mesh developed recalcitrant seromas. The mean size of prosthesis used was 353ml (range 200–500 ml). Extrusion occurred in eight breasts (two with mesh, six without). Mean coverage of the prosthesis by fascia was 74% (range 50–100%), and nine patients also had bilateral axillary liposuction of the axillary roll. Mean follow-up was 13 months. Conclusion Another technique for immediate prosthetic reconstruction providing an additional layer of prosthetic cover in prepectoral plane, without mesh. Applicable for all grades of ptosis. Extrusion rate is low. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Autologous coverage for direct-to-implant pre-pectoral reconstruction in large and ptotic breasts: a new technique

“…Recently, Hudson D.A. [ 48 ] also described the use of fascial flaps in pre-pectoral reconstruction. The latter technique [ 48 ] differs from our approach as the dissection of the pectoral and the serratus fasciae starts superiorly (infraclavicularly).…”

“…[ 48 ] also described the use of fascial flaps in pre-pectoral reconstruction. The latter technique [ 48 ] differs from our approach as the dissection of the pectoral and the serratus fasciae starts superiorly (infraclavicularly). Due to the limited distensibility of the fascial layer, this Hadson’s approach allows complete fascial coverage of just small size implants; in case a large or very high-profile prosthesis is required, the fascial flaps are combined with a small pectoral muscle flap or a mesh to cover the superior aspect of the implant or, alternatively, a two-stage expander-implant reconstruction is adopted.…”

“…Our technique, instead, is conceived for patients undergoing Wise pattern mastectomies and allows the placement of a definitive medium/large size implant. Scoring of the fascial flaps is also advocated by Hudson [ 48 ] to expand the lower portion of the pocket, whereas, in our technique, a good breast projection is maintained thanks to the combination of fascial flaps with the dermal sling. In case of extremely large breasts, complete coverage of a pre-pectoral implant with the sole inferior dermal sling has been also described in the literature [ 49 ].…”