Prosthetic breast reconstruction became possible following the introduction and commercialization of the silicone gel breast implant in the 1960s. With the evolution of oncologic and reconstructive techniques, there has been an associated decrease in local recurrence, increase in patient survival, reduction in adverse events, and increase in patient satisfaction.1,2 As surgeons are now able to reconstruct a natural breast mound, aesthetic expectations of the patient and the surgeon have increased and serve as a driving force to continually improve upon outcomes following mastectomy and reconstruction.
The ideal anatomical placement of prosthetic implants has been the subject of discussion and has changed over time. Prior to the use of tissue expanders, silicone and saline breast implants were placed in the prepectoral plane. However, the technique was abandoned due to a high incidence of infection, capsular contracture, and explantation that was ultimately due to thin mastectomy skin flaps and the lack of adequate soft-tissue support.3 The pursuit for implant support led to the adoption of complete muscular coverage with the pectoralis major and serratus anterior muscles. This provided vascularized soft-tissue coverage of the implant while decreasing the risk of capsular contracture.4 Later studies by Biggs and Yarish5 and Puckett et al.6 comparing subglandular versus subpectoral augmentation validated these findings, and they concluded that the submuscular plane provided a protective mechanism against capsular contracture.
Total muscle coverage was not without its setbacks. Contraction of pectoralis and serratus muscle often resulted in an unnatural animation deformity and sometimes caused pain due to muscle spasm.7,8 The introduction of acellular dermal matrices (ADMs) in 2006 revolutionized implant-based reconstruction by harnessing the benefits of partial muscle coverage for improved breast projection and by providing inferolateral tissue support.9 The ADM serves as a conduit by anchoring the inferior edge of the pectoralis major muscle to the inframammary fold, thereby minimizing the incidence of window shading. ADM also provides lateral support to minimize the incidence of lateralization associated with contraction of the pectoralis muscle and to better define the lateral mammary fold. This dual plane approach has become the most common method of prosthetic breast reconstruction.
The specialty of plastic surgery is characterized by innovation and ingenuity. The specialty is continually evolving by not only new ideas and inventions but also by recycling old ideas, revisiting old places, and refining historical techniques. Prepectoral breast reconstruction represents an old technique whose time has once again arrived based on the advancements in mastectomy and reconstruction. Plastic surgeons are once again able to reconstruct a breast using a prosthetic device that is placed in the subcutaneous plane.10–12 This, in addition to reconstructive adjuncts such as ADM and autologous fat grafting, has enabled the concept of the bioengineered breast to become a reality.13
TENETS OF PREPECTORAL RECONSTRUCTION AND PATIENT SELECTION
The importance of patient selection remains paramount in all surgical specialties and is especially true in the setting of prosthetic breast reconstruction.14 An established and collaborative relationship between the oncologic and reconstructive team facilitates our ability to successfully reconstruct a breast. Reconstruction is facilitated when the oncologic resection does not violate the borders of the breast, preserves the vascularity to the mastectomy skin flaps, and leaves the normal subcutaneous fat layer undisturbed. Unnecessarily compromising mastectomy flap thickness and vascularity may increase complications such as delayed healing, infection, and skin necrosis, all of which may interfere with adjunctive treatment.
The advantages of prepectoral breast reconstruction are somewhat transparent. The nature of the technique is less invasive and may be associated with less pain by leaving the pectoralis major muscle undisturbed.15 Its simplicity allows for decreased surgical and anesthesia times and has been demonstrated in 1 study to result in less narcotic use.15 One immediate and obvious advantage is the decreased animation deformity. The use of ADMs has been suggested and observed to decrease capsular contracture rates based on reducing the inflammatory response.16,17 Long-term benefits of prepectoral reconstruction remain theoretical; however, recent data with 2–3 year follow-up appear promising.18
The principle limitation of prepectoral device placement is that adequate soft-tissue support may be lacking in some cases; thus, proper patient selection is critical. Following mastectomy, the ligamentous structures that support the native breast are removed. Advocates of the dual plane techniques believe that the scar tissue/capsule generated on the undersurface of the fixed pectoralis major muscle helps to stabilize the prosthetic device and minimize inferior and lateral descent. Despite the theoretical benefit of the dual plane technique for device stabilization, malpositions remain common. With prepectoral reconstruction, the role of the ADM is to secure and stabilize the position of the prosthetic device on the chest wall and to provide additional tissue support. Since muscle contraction does not compress the device, there is less tendency for device malposition. The main concern with prepectoral reconstruction is that the lack of adequate tissue support can lead to implant rippling and palpability. However, as the thickness of the mastectomy flap increases, palpability of the implant should decrease. Later in this article, adjunct procedures that can help mitigate these risks will be reviewed.
Ideal candidates for prepectoral reconstruction are determined based on the integrity and quality of the mastectomy skin flaps following mastectomy.15 This tenet emphasizes the collaborative relationship between the plastic surgeon and breast surgeon. Maintaining the natural breast borders, both medially and inferiorly, as well as preserving the vascularity of mastectomy skin flaps is critical in creating the optimal device pocket. In some patients, performing a mastectomy may obviate the need for postoperative radiation. A potential conflict arises because there is a balance between achieving optimal mastectomy skin flaps and maintaining oncologic integrity. The primary consideration in all patients should be oncologic integrity; therefore, in patients with excessively thin skin flaps with visible dermis following mastectomy, dual-plane techniques should be preferentially considered. If severely compromised, delayed reconstruction should be considered.
Women with mild-to-moderate breast volume and optimized mastectomy skin flaps that desire to maintain current volumes are good candidates for prepectoral reconstruction. As the implant size increases, so do the supportive demands of the ADM and surrounding soft tissue. Women with mammary hypertrophy can still be candidates for prepectoral placement with skin reduction techniques.19 A favorable factor in obese patients or patients with mammary hypertrophy is that the mastectomy skin flaps are often thicker making prepectoral placement feasible. In patients with thinner skin flaps but with adequate adipose reserves, secondary fat grafting procedures to reduce implant visibility and to improve aesthetic outcomes can be considered.20
Relative and absolute contraindications for prepectoral reconstruction are similar to those of dual-plane reconstruction15 (Table 1). Patients with inadequate vascularity of the mastectomy skin flaps and patients actively using tobacco products are poor candidates for reconstruction and should be delayed. Fluorescent angiography with indocyanine green at the time of mastectomy is helpful in discerning the skin flap perfusion.21 Urine cotinine testing is an objective method to identify occult tobacco users. Uncontrolled diabetes mellitus, hemoglobin A1C levels > 7.5%, BMI > 40, and an immunocompromised state are additional factors that determine poor surgical candidacy primarily due to the increased likelihood of poor wound healing. The oncologic status of the patient is also an important factor in determining reconstructive candidacy. Prepectoral reconstruction should be critically evaluated and possibly avoided in patients with tumors greater than 5 cm, gross chest wall involvement, close proximity to the pectoralis major muscle, and with gross axillary involvement. The need for future radiation is often not known at the time of reconstruction; however, prior radiation therapy to the affected breast places the reconstruction at risk of infection, capsular contracture, and poor wound healing. This is an area that requires further study.
Surveillance for recurrence in prepectoral patients is another important consideration. When the pectoralis major muscle is abutting the mastectomy skin flap as with the dual plane techniques, recurrence on the muscle can sometimes be palpated; however, when the implant is atop the pectoral muscle, palpability is not possible. Therefore, in patients at increased risk for local recurrence, periodic magnetic resonance imaging scans are recommended or the traditional dual plane techniques are preferentially considered.
Prepectoral implant placement is not a new reconstructive or aesthetic technique. Prior to several recent technologic advancements in plastic surgery, implant rippling and implant descent were significant drawbacks of subcutaneous device placement. With the advent of ADM, autologous fat grafting, and tissue perfusion technology, prepectoral reconstruction is feasible. The concept of the bioengineered breast highlights the advantages of ADMs and fat grafting on the aesthetic outcomes in breast reconstruction.13 The ability to construct a partial submuscular pocket while maintaining inferolateral support allowed the dual plane prosthetic reconstruction to become the most common. A decade has passed since the introduction of ADM and there have been substantial improvements. ADM is now available in multiple sizes and shapes, is ready to use without the need for prolonged hydration, comes with or without perforations, and now has more uniform thickness of the individual sheets. ADM use has been shown to decrease capsular contracture rates16,22 and result in more natural breast contours.23 ADMs contribute to the success of prepectoral breast reconstruction as it provides a customized, hand-in-glove fit, to support the mastectomy skin flaps and provide a surface layer that results in less scar formation.
Advancements with implant and tissue expander technology have also contributed to the success of prepectoral reconstruction. Tissue expanders have improved shells and injection ports as well as tabs to prevent implant migration.24 Silicone gel implants are now optimally filled with more cohesivity to reduce implant rippling, wrinkling, and visibility. Silicone implants are available in round and anatomic shapes, and optimal selection is based on breast characteristics and patient expectations. These characteristics result in less rippling and wrinkling, even in patients with thinner skin flaps.
Finally, the role and benefits of autologous fat grafting have also been demonstrated in the setting of prosthetic breast reconstruction.20 Autologous fat grafting provides additional soft-tissue coverage by thickening the subcutaneous tissues. It improves the aesthetic result by camouflaging the upper pole and increasing overall breast volume. This technique may be performed at the expander to implant exchange or as a separate procedure. Fat grafting requires a vascular recipient bed for survival. Thus, fat grafting should not be performed at the time of mastectomy or if multiple capsulotomies have been made at the time of tissue expander exchange. Several rounds of fat grafting are often necessary that can further improve outcomes.
Proper patient selection is the most critical factor in prepectoral implant-based breast reconstruction. Upon completion of the mastectomy, critical evaluation of the remaining mastectomy skin flaps and associated vascularity is paramount (Fig. 1). If the quality of the soft tissues appears compromised, the decision to proceed with traditional dual plane placement of tissue expanders or delaying the reconstruction by 2 or 3 weeks should be considered.25 Laser angiography with indocyanine green is a useful adjunct to assist the surgeon in assessing the viability of the mastectomy skin flaps.21 Laser angiography is often considered in the setting of direct-to-implant reconstruction.
Another tenet in prepectoral breast reconstruction is the pocket size and its relation to the implant. The goal is to create a hand-in-glove fit between the implant and the periprosthetic space19 (Fig. 2). Various factors will increase the likelihood of this happening and include thick mastectomy skin flaps, properly sized implants, and highly cohesive/optimally filled implants. A periprosthetic pocket that is larger than the implant will often result in more rippling, wrinkling, and visibility. An advantage of the 2-stage techniques is that permanent implant selection can be optimized based on the known variables such as tissue expander volume, quality of the mastectomy skin flaps, and patient expectations. Other benefits of 2-stage reconstruction include mild contraction of mastectomy skin flaps when the tissue expander is in place as well as mild-to-moderate ptosis correction, particularly in the setting of nipple-sparing mastectomy. In both 1- and 2-stage reconstruction, the placement of the prosthetic device is based on similar principles and routinely covered by an ADM.
ADMs are commonly used in the setting of prepectoral devices primarily because they provide additional tissue support and may decrease the incidence capsular contracture. The senior surgeon prefers thick AlloDerm (LifeCell, an Allergan company, Branchburg, N.J.) measuring 2–3 cm in thickness for soft-tissue support (Fig. 3). Two sheets of medium, contoured, perforated AlloDerm are used for each breast and are sewn together using an absorbable suture (Fig. 4). Alternatively, a single large sheet of ADM measuring 16 × 20 cm can be used. The ADM is sized by draping it over the expander or the permanent implant with the seam oriented in either the vertical or horizontal direction depending on the dimensions of the device (Fig. 5). The tissue expander can be filled with air or saline, but our usual practice is to fill with a known quantity of air. The reasons are to off load the pressure on the lower mastectomy skin flap, minimize suture pull-through of the tab-muscle junction, and for patient comfort. When ADM is used in conjunction with a tissue expander, the ADM should have a mild degree of laxity to allow for future expansion. The degree of laxity is similar to that of the dual plane technique. When ADM is used in conjunction with a permanent implant, the ADM should conform to the shape of the implant without laxity. With direct-to-implant reconstruction through an inframammary incision, the authors’ approach is to suture the ADM in the superior pocket first, followed by suturing the medial and lateral borders of the ADM to the chest wall. The tissue expander or implant is then inserted and the ADM is sutured inferiorly. This represents the on-label approach as stated by the U.S. Food and Drug Administration based on providing tissue support. An alternative off-label strategy is to wrap the ADM around the device and secure it with spanning sutures and then insert the construct into the mastectomy pocket.
Prior to device insertion, the skin is reprepped with a povidone-iodine solution and redraped to maintain sterile technique. The mastectomy pocket is irrigated with a half-strength povidone-iodine solution followed by a triple antibiotic solution. Hemostasis is confirmed and the expander/implant/ADM construct is placed into the defect. The tissue expander is fixated to the underlying pectoralis major muscle using absorbable sutures to anchor the expander tabs (Fig. 6). The ADM is also fixated to the pectoralis circumferentially with interrupted absorbable suture to reinforce the reconstruction. A single closed suction drain is placed between the ADM and the mastectomy skin flap and tunneled subcutaneously several centimeters to prevent retrograde bacterial migration. The mastectomy edges are closed in layers with absorbable sutures. A postoperative surgical bra with lateral padding is placed to prevent device migration and rotation in the immediate postsurgical period.
Patients are seen weekly until drain removal. Postoperative oral antibiotics are usually discontinued at the first postoperative visit and do not correlate with drain removal. Drain use is usually maintained for 1–2 weeks and until the output is < 30 cc/24 hours. Following drain removal, patients are seen weekly for expansion. Patients with air-filled tissue expanders usually have the air extracted at 2 weeks followed by saline instillation. The exchange of the tissue expander to permanent implant usually occurs at 3 months but may be later when chemotherapy or radiation therapy is necessary. In some cases, the exchange may occur before radiation therapy. In nonradiated patients, the old mastectomy incision is incised and extends through the ADM. In radiated patients, a counter incision along the inframammary fold is made and extends through the ADM or capsule. Following insertion of the permanent implant, the ADM is repaired and the skin incision closed in layers. Patients are seen postoperatively at 1 week, 6 weeks, 3–6 months, and then yearly. Figures 7–9 illustrates a patient following skin-sparing mastectomy and prepectoral reconstruction, and Figures 10 and 11 illustrate a patient following nipple-sparing mastectomy and prepectoral reconstruction.
Literature Review and Outcomes
The resurgence of the prepectoral technique is relatively recent, yielding limited follow-up and long-term outcomes. The lack of outcome data rightfully fuels a skeptical perspective on the longevity of results. There are several recent studies that have been published demonstrating the safety, efficacy, and patient satisfaction following prepectoral breast reconstruction. Vidya et al.26 recently published a prospective multicenter study with data collected from 2014 to 2015 on 100 prepectoral breast reconstructions using Braxon dermal matrix.28 Their results showed 2% implant loss due to nipple necrosis or wound break down. The average follow-up for the patient population was 17.9 months with no observed rotation or loss of shoulder range of motion.
Similarly, Sigalove et al.15 have adopted prepectoral reconstruction in select patients since 2008. Their retrospective review of 353 prepectoral reconstructions using AlloDerm in 207 patients resulted in a 4% infection, 2% seroma rate, and 2.5% skin flap necrosis rate. Woo et al.18 have demonstrated high success rates with subcutaneous reconstruction as well. In his retrospective review of 135, single surgeon reconstructions using AlloDerm, 96% of patients had successful reconstruction, with only 14% having minor nonsurgical complications. Bottoming out has not been reported in these studies nor has it been observed as sequelae of the prepectoral technique in the authors’ personal experience. This is most likely due to strict attention to patient selection criteria as well as surgical technique to secure the inframammary fold and to provide adequate soft-tissue support with the ADM. Comparative studies between prepectoral and total muscle coverage breast reconstruction have demonstrated similar morbidities with regard to infection, superficial skin necrosis, and seroma but decreased rates of capsular contracture.12,28
Patients requiring significant skin reduction at the time of mastectomy may also be good candidates for prepectoral reconstruction. Several techniques have been described to reduce the skin envelope without significantly compromising mastectomy skin flap vascularity. Caputo et al.19 reviewed 33 reconstructions and demonstrated no implant loss in immediate reconstruction following nipple-sparing mastectomy. Only 2 patients required surgical debridement of necrotic tissue.
Though ADMs have been widely adopted by plastic surgeons, Salibian et al.29 have demonstrated that thick mastectomy skin flaps and strict preservation of the native inframammary fold may obviate the need for ADM. Their 10-year retrospective review of 250 prepectoral breast reconstructions without ADM reveal promising results. Clinically significant capsular contracture was seen in 7.6% of patients and implant displacement in 0.8%. Aesthetic outcomes were graded as good to very good in 85.2% of patients. The oncologic safety of “thick mastectomy skin flaps” has been scrutinized. This study showed a tumor recurrence rate of 2.6% after an average of 55 months, which is in line with current literature.
The issue of cost using ADM is certainly a factor when considering prepectoral reconstruction. Human ADM is expensive and will certainly incur additional costs that range from $5,000 to $20,000 per breast. Prepectoral options do not all require the use of human ADM but can include no ADM as well as alternative materials that include titanium-coated polypropylene mesh,12 vicryl mesh,11 as well as porcine mesh.10 All have demonstrated success in the prepectoral setting and may have cost-saving benefits.
Prepectoral reconstruction is a resurfacing of a previous concept from the 1960s that was abandoned by previous plastic surgeons due to lack of adequate soft tissue resulting in a unacceptably high complication rate. Most of these shortcomings were due to thin mastectomy skin flaps and an inability to provide adequate tissue support. The use of ADMs and autologous fat grafting has enabled surgeons to achieve a greater degree of soft-tissue support and hence improve outcomes. This has been associated with a significant reduction in the rates of capsular contracture. Vardanian et al.30 demonstrated that immediate reconstruction with ADM resulted in capsular contracture rates of 3.9% at 2.5 years versus 19.4 % when no ADM was used. The pathology behind capsular contracture has been studied at length but is not completely understood. However, Basu et al.16 have shown that ADM may have inherent properties that significantly limit the amount of inflammation and thus pathologic capsule formation. Comparative biopsies of submuscular native capsule and ADM were taken at the time of implant exchange and were able to demonstrate decreased granulation tissue, vessel proliferation, fibrosis, fibroblast cellularity and foreign body reaction in the ADM cohort compared with the native capsule.
A potential drawback to prepectoral reconstruction is the lack of soft-tissue support over time that may result in visible rippling and wrinkling. With the useful adjuncts to minimize this occurrence such as ADM, autologous fat grafting and cohesive breast implant, this can me minimized, albeit not eliminated.
There is increasing evidence to support the resurgence of prepectoral breast reconstruction. Both 2-stage and direct-to-implant reconstruction are gaining popularity in the prepectoral plane with good aesthetic results. Though this technique is not suited for all reconstructions, strict attention to proper patient selection is imperative to its success. This revival is due to a culmination of factors that reflect the evolution of breast implant properties that resist rippling, the availability of dermal tissue matrices for implant support, and the refinement of fat grafting techniques coupled with breast surgeons that preserve the normal subcutaneous layer of the breast. As the technique continues to progress, more long-term data will become available to assess aesthetic outcomes.
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Copyright © 2017 by the American Society of Plastic Surgeons
30. Vardanian AJ, Clayton JL, Roostaeian J, et al. Comparison of implant-based immediate breast reconstruction with and without acellular dermal matrix. Plast Reconstr Surg. 2011;128:403e410e.