Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score–Matched Comparison of Perioperative Outcomes

Abstract

Background:The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking. Methods: Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors. Results: Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis. Conclusions: Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.

Tissue expansion techniques in reconstructive surgery: a 10-year bibliometric analysis

“…Its advantages include the elimination of animation deformities and muscle spasms. Studies have also shown that it is associated with less pain, is time-saving, and provides excellent aesthetic outcomes ( 46 - 48 ). Candidates for prepectoral breast reconstruction should have well-vascularized skin flaps and sufficient fat depots for fat grafting based on the concept of a bioengineered breast ( 49 ).…”

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction

“… 58 , 59 Thus, these techniques cannot be assessed in this trial, and the results’ applicability to such techniques is uncertain. According to recent studies, 60 , 61 , 62 , 63 , 64 , 65 , 66 however, the prepectoral position (which, in principle, always includes some type of mesh) renders no higher SSI rates compared with the subpectoral position, so multiple-dose antibiotic prophylaxis is probably not indicated.…”

The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study

“…Patient-reported outcome scores are effective in determining patient satisfaction and quality of life, but it is also important to address postoperative complications. There is no consensus on whether prepectoral versus subpectoral placement is associated with more complications, but prepectoral has been associated with higher seroma rates [ 27 , 28 ]. Though our TE removal rates were higher than previously reported values, the complication rates in the prepectoral cohort of Haddock et al were similar to ours [ 28 ].…”

“…There is no consensus on whether prepectoral versus subpectoral placement is associated with more complications, but prepectoral has been associated with higher seroma rates [ 27 , 28 ]. Though our TE removal rates were higher than previously reported values, the complication rates in the prepectoral cohort of Haddock et al were similar to ours [ 28 ]. Though the current evidence suggests that certain patients can undergo reconstruction without ADM, longer term, prospective studies are needed for definitive answers [ 29 ].…”