As prosthetic breast reconstruction with the prepectoral technique continues to evolve, there are many questions about when and for whom this procedure should be offered. For the past 20 years, partial or total muscle coverage techniques in the setting of prosthetic reconstruction have been the gold standard.1,2 Given the relative novelty of the prepectoral technique, many surgeons are unsure about safety and efficacy parameters.3–5 Questions about candidacy and technique are common for a variety of reasons, including variations in surgical technique, variations in mastectomy quality, and divergence of opinion among the experts. It is clear that an algorithm that incorporates the various controversies with prepectoral reconstruction is warranted to allow plastic surgeons to perform this technique with enhanced predictability and reproducibility.
The purpose of this article is to provide current approaches, recommendations, and an algorithm that will encompass the various factors associated with prepectoral reconstruction that can positively and negatively affect outcome. The intent of this article is not to imply that one technique is better than another, because the reality is that many of the variations will work based on surgeon preference and experience. Topics focus on preoperative, intraoperative, and postoperative strategies.
Proper patient selection is arguably one of the most important considerations in plastic surgery. During the initial consultation, both the prepectoral and subpectoral (dual-plane) techniques are discussed. Benefits and limitations of each are reviewed and have been described previously.3,4,6 Ideal candidates for prepectoral reconstruction include patients with a body mass index less than 30 kg/m2, patients with mild to moderate breast volume, nonsmokers, patients with minimal ptosis, patients having prophylactic mastectomy, and patients with central breast tumors.3,4 Less ideal candidates include those with poorly controlled diabetes mellitus with a hemoglobin A1c value greater than 7.5, tobacco use, immunocompromise, previous radiation therapy, and morbid obesity.7 This population of patients will have an increased incidence of delayed incisional healing, mastectomy skin flap necrosis, infection, seroma, and reconstructive failure relative to ideal candidates. With increasing experience, some of these factors such as obesity and prior radiation therapy can be considered and would therefore be classified as relative contraindications. However, poorly controlled diabetes mellitus, severe immunocompromise, and active tobacco use are absolute contraindications based on personal experience with reconstructive failure. Tumor location is another important consideration. Many oncologists feel that in patients with tumors that are within 5 mm of the pectoralis major muscle, prepectoral placement of a prosthetic device should not be considered because it may hinder palpation of a recurrence.8 Superficial tumors may result in mastectomy skin flaps that are too thin with compromised vascularity and therefore hinder the ability to safely perform prepectoral reconstruction.
IMMEDIATE PREPECTORAL VERSUS IMMEDIATE SUBPECTORAL VERSUS DELAYED RECONSTRUCTION
Mastectomy skin flaps can vary based on thickness, dimensions, and perfusion; therefore, skin flap assessment is a critical component and determinant of success (Figs. 1 and 2). An algorithm for prosthetic reconstruction based on the perfusion and thickness of the mastectomy skin flaps is provided in Figure 3. Skin flap perfusion can be determined clinically by evaluating skin color, capillary refill, and adequate arterial and venous bleeding along the incisional edges, and by using perfusion assessment tools such as fluorescent angiography. Personal experience with fluorescent angiography has been positive, and it can demonstrate whether tissue perfusion is sufficient or not. However, it is important to recognize that several factors can alter early tissue perfusion, including vasospasm, hypothermia, and hypotension.
The thickness of a mastectomy skin flap is less important than the perfusion. Thin patients typically have thin mastectomy flaps and overweight or obese patients tend to have thicker mastectomy skin flaps. The normal subcutaneous layer of the breast varies from person to person and ranges from 2 to 3 cm.9 In situations where the mastectomy skin flaps are thicker and well perfused, either a tissue expander or a permanent implant can be placed in the prepectoral space. In situations where the skin flap is thin but adequately perfused, the safest approach is to place a minimally filled tissue expander in the prepectoral or subpectoral space. It is generally agreed on that visibility of dermis throughout the undersurface of the mastectomy skin flap is a contraindication to prepectoral reconstruction because of an increased likelihood of mastectomy skin flap necrosis and reconstructive failure. Total muscle coverage of a tissue expander can be considered in this situation; however, it is preferred to delay the reconstruction. Zenn popularized the option of delayed immediate reconstruction in an attempt to minimize the incidence of reconstructive failure associated with mastectomy skin flap necrosis in the immediate setting.10 It is well accepted that delayed reconstruction has fewer adverse events.10,11
Management strategies for skin necrosis following dual-plane or total muscle coverage techniques include allowing the skin necrosis to declare itself followed by surgical débridement (1 to 2 weeks). The pectoralis major served as a protective barrier and protected the device from exposure. In the prepectoral setting, however, prompt and aggressive management is essential, because there is no protection afforded by the pectoral major muscle. When mastectomy skin flap necrosis is evident in the setting of prepectoral device placement, early débridement is advocated (<1 week) to avoid exposure of the device and acellular dermal matrix. Exposure of the device will increase the likelihood of reconstructive failure.
When the delayed approach is performed, the mastectomy skin flaps are closed over a drain. It is important to monitor the flaps regularly in the office for signs of necrosis. If there is no skin necrosis, the patient is taken back to the operating room, usually within 2 to 3 weeks, for prepectoral device placement. Reoperation within 1 to 3 weeks of the mastectomy will permit relative ease of elevating the skin flaps, recreating the mastectomy pocket, and placing a device. Reoperation after 3 to 4 weeks usually results in mastectomy skin flap contracture and scar formation and almost always requires placement of a tissue expander.
When mastectomy skin flap necrosis does occur during the observation period, débridement and closure are advocated. Device placement at the time of débridement is not recommended because of the probability of soft-tissue contamination and device infection. When management is protracted beyond 1 month, ancillary measures such as autologous fat grafting are considered before prosthetic reconstruction. Fat grafting is typically performed at 3-month intervals, whereas delayed device insertion is considered 2 to 3 weeks after the débridement. In the event that the patient requires adjuvant therapy such as chemotherapy or radiation therapy, reconstruction is usually deferred and performed following all adjuvant therapy.
One of the primary limitations of immediate prepectoral reconstruction is the added cost associated with using acellular dermal matrix. Although a cost analysis in the setting of prepectoral reconstruction has not been performed, the cost-effectiveness of acellular dermal matrix in the setting of dual-plane expander/implant breast reconstruction has been studied and demonstrated a baseline increase in cost of $361.96 when a single sheet of acellular dermal matrix was used.12 This was associated with an increase in quality-adjusted life-years of 1.37, with a cost-effective incremental cost-utility ratio of $264.20 per quality-adjusted life-year. Although there is a lack of long-term data and outcomes with prepectoral reconstruction, short-term outcomes are favorable.
ACELLULAR DERMAL MATRIX VERSUS NO ACELLULAR DERMAL MATRIX
The use of acellular dermal matrix in the setting of prepectoral reconstruction is common13–16 but not universal.17,18 Reasons to use acellular dermal matrix include added tissue support, minimizing the inflammatory response associated with implants, minimizing scar contracture, compartmentalizing the device, and minimizing the risk of malposition. Reasons to avoid acellular dermal matrix include high cost, healthy and well-perfused mastectomy skin flaps, and high-quality outcomes without it.18 Data analyses comparing prepectoral studies with and without acellular dermal matrix are mixed but have consistent findings.13–21 In general, infection and skin-related complications are similar between the two cohorts, but capsular contracture rates are generally less when acellular dermal matrix is used (Tables 1 and 2).
The controversy regarding acellular dermal matrix use for prepectoral reconstruction is complicated and ultimately based on the surgeon’s philosophy. The data regarding acellular dermal matrix use are mixed and include supportive and nonsupportive outcomes. An algorithmic approach for prepectoral reconstruction based on high-level evidence is difficult because the early data outcomes are similar between prepectoral and dual-plane reconstruction and surgeons’ opinions are polarized. However, the data do support that capsular contracture rates are less when acellular dermal matrix is used.1,3,4 The use of acellular dermal matrix requires the surgeon to consider several variables related to the acellular dermal matrix that include thickness, partial or total coverage of the device, need for perforation or fenestration, drain number and duration, and type of suture material used. Alternatives to acellular dermal matrix use include synthetic mesh such as titanium-coated mesh and Vicryl (Ethicon, Inc., Somerville, N.J.).22
Acellular Dermal Matrix Thickness, Perforation, and Incorporation
There is a consensus that with prepectoral reconstruction, thicker sheets of acellular dermal matrix (2 to 3 mm) are preferred, based on the need for additional soft-tissue support and to provide stability to the implant. The integration and incorporation of acellular dermal matrix is a function of mastectomy skin flap perfusion and minimizing the accumulation of fluid between the subcutaneous fat and acellular dermal matrix (Fig. 4). Perforated or fenestrated acellular dermal matrix will permit bidirectional flow of fluid and minimize the accumulation of fluid between the acellular dermal matrix and the mastectomy skin flap (Fig. 5). In addition, the perforations will create zones of adherence between the acellular dermal matrix and the mastectomy skin flaps, thus promoting incorporation and minimizing seroma formation.23
The lack of acellular dermal matrix integration can pose a surgical dilemma (Fig. 6). With the traditional dual-plane technique, unincorporated acellular dermal matrix was typically removed, because once the position of the pectoralis major muscle was stabilized along the mastectomy skin, the acellular dermal matrix provided little additional support in terms of device compartmentalization. However, with prepectoral reconstruction, unincorporated acellular dermal matrix is not removed. When lack of incorporation is noted at the time of device exchange, the undersurface of the mastectomy skin flap is scored or abraded to recreate a raw surface. A closed suction drain is placed between the acellular dermal matrix and the mastectomy skin flap to promote acellular dermal matrix incorporation. Quilting sutures can also be considered to secure the acellular dermal matrix to the mastectomy skin.
Partial versus Total Acellular Dermal Matrix Coverage
There is considerable controversy as to whether it is preferable to partially (180-degree) or totally (360-degree) wrap the acellular dermal matrix around the device.24–27 There is also controversy as to whether it is better to sew sheets of acellular dermal matrix together (Fig. 4) or to use a large continuous sheet (Fig. 7). The various assembly options have been described previously.27 What will be reviewed is the author’s preferred approach and algorithm.
The shapes of acellular dermal matrix sheets are variable and include contoured or rectangular sheets, with various size options that include small, medium, and large for the contoured and 16 × 4, 16 × 6, 16 × 8, and 16 × 20 cm for the rectangular sheets (Figs. 5 and 7). When a total wrap is performed, two or more sheets per breast are typically used. With a partial wrap, options include a single large rectangular sheet or two sheets of contoured medium perforated acellular dermal matrix that are sewn together along the short curved axis (Fig. 4). This option provides a three-dimensional construct that drapes over the implant with minimal pleating, whereas the rectangular sheet will have a greater degree of pleating. The issue of acellular dermal matrix instability or widening at the seam has not been observed (Fig. 8).
The method by which the acellular dermal matrix is placed into the prepectoral space varies. U.S. Food and Drug Administration labeling requires that acellular dermal matrix for breast reconstruction be used for tissue support and not implant support; thus, there are on-label and off-label techniques by which acellular dermal matrix is used. With the on-label technique, the acellular dermal matrix is inserted into the prepectoral space and sutured to the perimeter of the pocket in accordance with the dimensions of the tissue expander or permanent implant (Fig. 9). Following acellular dermal matrix placement, the device is inserted and optimally positioned. The acellular dermal matrix position can be adjusted to create a hand-in-glove fit around the device. With this technique, an inferior gutter of acellular dermal matrix along the inframammary fold is created to provide increased lower pole support.
With the off-label technique, the acellular dermal matrix is draped around the anterior aspect of the tissue expander or implant, creating a peripheral cuff (Fig. 10). The device is then turned upside-down without disrupting the acellular dermal matrix/device interface. Sutures are placed along the posterior aspect of the device spanning from one edge of the acellular dermal matrix to the other edge to create an acellular dermal matrix/device construct (Fig. 11). Polyglactin sutures are preferred because the knots have more grip strength and are less likely to unravel. The acellular dermal matrix/device construct is then placed into the prepectoral space, properly positioned and oriented (Fig. 12). When a tissue expander is used, the tabs are exteriorized from within the acellular dermal matrix envelope and sutured to the chest wall. When a permanent implant is used, the edges of the acellular dermal matrix at the base of the implant are sutured circumferentially around the perimeter of the pectoralis major muscle. Other methods of acellular dermal matrix assembly have been described previously.27
ONE-STAGE VERSUS TWO-STAGE RECONSTRUCTION
There remains moderate controversy as to whether it is best to perform one- or two-stage reconstruction in the setting of prepectoral placement.24–26 This decision ultimately depends on the perfusion and thickness of the mastectomy skin flaps. When insertion of a prefilled device in the prepectoral space is desired, it is especially important to assess tissue perfusion with fluorescent angiography. This will provide the best indicator as to safety, especially in the setting of nipple-sparing mastectomy. When fluorescent angiography is used, it is best to assess perfusion at least 30 minutes after the mastectomy to provide enough time for vascular spasm within the mastectomy skin flap to subside. It is also important to ensure that the patient is normothermic and normotensive. If perfusion is compromised or questionable, direct-to-implant reconstruction should be avoided. It is important to remember with one-stage prepectoral implant placement that there is no protection afforded by the pectoralis major muscle; therefore, the thickness of the mastectomy skin flaps must be sufficient to support the implant. Although there is no thickness threshold that is ideal, it is this author’s approach to consider one-stage reconstruction when the thickness of the mastectomy skin flap is greater than 1 cm. Repeated angiography following implant insertion is advised to ensure that perfusion remains adequate.
Classic use of tissue expanders is usually associated with saline instillation. However, with prepectoral tissue expanders, the device can be filled with saline or room air. Advocates for air will cite even distribution throughout the expander, less suture pull-through at the tab-muscle interface, patient comfort, and offloading of pressure on the lower mastectomy skin flap.28 Once the air-filled tissue expander/acellular dermal matrix construct is inserted into the prepectoral space and optimally positioned, the tabs are sutured to the pectoral muscle with three-point fixation. During the postoperative follow-up, all air is usually evacuated between 1 and 2 weeks and replaced with an equal or increased amount of saline (Fig. 13). This is especially important in patients that will be receiving postoperative radiation therapy, as air will tend to diffuse out of the expander over time and may disrupt the previously planned simulation. If desired, continuation with air expansion can be considered.
Prepectoral reconstruction can be performed with a variety of devices ranging from tissue expanders to permanent implants.29,30 Although prepectoral reconstruction with tissue expanders can be performed with or without suture tabs, the use of suture tabs has been beneficial (Fig. 7). The base width of the tissue expander is important for proper alignment with the breast footprint. The projection of the tissue expander is less relevant when it comes to the safety of this procedure but is an important consideration when assessing patient expectations. Tissue expanders with integrated and remote ports can be used. Given the temporary nature of tissue expanders, permanent implant selection is the more important consideration.
The most important feature of a permanent implant in the setting of prepectoral reconstruction is the degree of cohesivity. Highly cohesive implants are desirable because they are less likely to ripple and wrinkle. Saline implants and less cohesive silicone gel devices are more prone to rippling. Following a mastectomy, extra projecting highly cohesive silicone gel implants are preferred; however, it is important that the permanent implant fit like a hand-in-glove within the mastectomy pocket. A loose fitting implant may be more prone to flip within the pocket and result in a visible contour abnormality. Surface texture of the permanent implant is less important when acellular dermal matrix is used but more important without acellular dermal matrix. Texture can provide adherence to the soft tissue and maintain device stability and reduce capsular contracture, especially when anatomical devices are used.
POSTOPERATIVE CARE AND COMPLICATIONS
Following prepectoral reconstruction, incisional and breast management varies among surgeons. Options include antibacterial dressings, Tegaderm (3M, St. Paul, Minn.), incisional vacuum-assisted closure devices, and surgical bras. The incisional vacuum-assisted closure may minimize fluid production within the periprosthetic space and reduce seroma formation.31 A Tegaderm splint is applied over the breast mound following nipple-sparing mastectomy to reduce shear forces that may displace the nipple-areola complex (Fig. 14). A soft compression bra is usually applied to provide stability and mild compression to the reconstructed breast mound that can reduce seroma formation.32 Patients are typically asked to minimize strenuous activity for the first month, as this may stimulate fluid production and seroma formation.
During the first postoperative visit, the mastectomy skin flaps are thoroughly inspected for signs of ischemia, nipple-areola necrosis, swelling, fluid collections, infection, and delayed healing. Because these reconstructions are prepectoral, prompt intervention is required in the setting of an adverse event. Necrotic skin must be débrided promptly (Fig. 15). Erythema must be managed appropriately with antibiotics to rule out infection. If the erythema is diffuse or aggressive, intravenous antibiotics are implemented. Persistence will require operative exploration. If there is gross purulence, the implant and the acellular dermal matrix are removed. If there is turbid fluid, salvage may be considered by aggressive irrigation and débridement and placement of a new device.
Drain management can vary, but most surgeons tend to remove them when output is less than 30 cc/day for 2 consecutive days but not before 1 week. In the event of elevated output, drains are used for up to 4 weeks but are removed after that to minimize infection risk. Serial expansion is commenced at the 2-week mark regardless of the presence of a drain or output. In the event of a seroma, aspiration is considered with a moderate-bore needle, taking strict care not to puncture the device. If the seroma is refractory, options include ultrasound-guided drain placement or operative exploration. Because seroma formation is associated with autoexpansion, the tissue expander can be exchanged for a permanent implant at the time of seroma evaluation and management. If the acellular dermal matrix is partially adhered or nonadhered, it is retained and a new implant and drain are inserted.
In the event of rippling and wrinkling, several factors require consideration, including the thickness of the mastectomy skin flaps, the implant-to-mastectomy ratio, and the degree of implant cohesivity. Rippling and wrinkling are common in the setting of prepectoral reconstruction. Autologous fat grafting is usually performed to increase the thickness of the mastectomy skin flaps.3–5,24 Typically, 50 to 100 cc of fat is injected into the subcutaneous plane in each breast. Additional fat grafting can be performed at 3-month intervals. In some patients, rippling may be caused by an overexpanded pocket. Pocket modification by means of capsulorrhaphy and exchange for a highly cohesive implant can be corrective. It should be remembered, however, that some degree of mild rippling with prepectoral reconstruction is normal.
This article was prepared to provide the reader with current approaches, recommendations, and an algorithm for prepectoral prosthetic breast reconstruction. Although this procedure seems relatively simple, there are many nuances that require attention to achieve predictability, reproducibility, and an aesthetically pleasing result.
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Copyright © 2018 by the American Society of Plastic Surgeons
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