Surgical Correction of Breast Animation Deformity with Implant Pocket Conversion to a Prepectoral Plane

Abstract

Background: Animation deformity is an undesirable outcome of subpectoral breast reconstruction that results in abnormal breast contraction with activity, breast pain, and increased implant visibility. Surgical correction requires implant removal and conversion of the reconstruction to a prepectoral plane. The authors present their institutional experience with their preferred surgical technique to treat this challenging problem and outline solutions for increased success in these patients. Methods: A retrospective review was performed of all patients undergoing conversion of their subpectoral breast reconstruction to a prepectoral plane at the authors’ institution. Patient demographics and surgical details were analyzed, and postoperative outcomes and morbidity were assessed. The effects of changing operative strategies on enhanced success are also reported. Results: A total of 80 breast conversions were performed over a 2.5-year period. All patients demonstrated resolution of animation deformity at a mean follow-up of 15.2 months. Two reconstructions (2.5 percent) required an unplanned return to the operating room, and 11 reconstructions (13.8 percent) were treated for infection. Preconversion fat grafting and the use of acellular dermal matrix were both associated with a reduced incidence of postoperative asymmetry and capsular contracture (p < 0.05). There were no reconstructive failures associated with conversion to a prepectoral pocket. Conclusions: Treatment of animation deformity in the reconstructed patient can be safely performed by surgical conversion to a prepectoral plane. The use of acellular dermal matrix, and preconversion fat grafting, in appropriate patients can improve results. The authors promote this operative algorithm for all reconstructive patients experiencing symptomatic animation deformity with subpectoral breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.…”

“… 22 , 29 , 30 In detail, one study excluded patients with pinch test of less than 2 cm; 22 one study excluded patients with pinch test less than 1.5 cm at the upper pole of the breast; 29 the last study excluded patients with pinch test less than 1 cm without availability of fat graft donor sites. 30 Sixty-one patients underwent preoperative fat grafting. In one study, previous radiation therapy, active smoking, poor skin perfusion, and uncontrolled diabetes were considered as exclusion criteria.…”

“…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.…”

“… Anterior or subtotal capsulectomy Anatomic textured implants with a high or extra high projection (range 265‐615 cc). Braxon Total implant coverage Holland, 2020 30 The inferior border of the pectoralis muscle is identified and incised, to gain access to the preexisting implant and capsule, both of which are removed. Complete capsulectomy when possible.…”