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Breast: Original Articles

Dual-Plane versus Prepectoral Breast Reconstruction in High–Body Mass Index Patients

Gabriel, Allen M.D.; Sigalove, Steven M.D.; Storm-Dickerson, Toni L. M.D.; Sigalove, Noemi M. M.D.; Pope, Nicole M.S.N., F.N.P.-C., C.P.S.N.; Rice, Jami M.S.P.A.S., P.A.-C.; Maxwell, G. Patrick M.D.

Author Information
Plastic and Reconstructive Surgery: June 2020 - Volume 145 - Issue 6 - p 1357-1365
doi: 10.1097/PRS.0000000000006840
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Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m2) is technically challenging, involves longer operative times and longer hospital stays, and is associated with increased postoperative medical and surgical complications.1,2 Postsurgical complications including wound complications, infections, seroma, skin necrosis, return to the operating room, prosthesis loss, and reconstructive failure appear to increase with progressive increase in BMI.1,3,4 High-BMI patients also tend to have a higher incidence of comorbid conditions1 that may contribute to postoperative complication or complicate reconstructive surgery.

Although several reconstructive options are available for patients following mastectomy,5 the optimal approach for high-BMI patients remains to be determined. In the past, immediate device-based reconstruction was discouraged in high-BMI patients because of the high complication rates. In contrast, autologous options were encouraged in these patients but donor-site morbidity became an additional area of concern and source of complications. In the current era, autologous options are considered to be less favorable, as they are associated with higher postoperative complications compared with prosthetic reconstruction.2 The prosthetic option, however, is not any better, because every unit increase in BMI increases the odds of complications by 6 percent and reconstructive failure by 8 percent.6 Furthermore, given the substantial risk associated with high BMI, reconstructive surgeons may delay reconstruction in these patients.7

Although prosthetic reconstruction is typically performed by means of the dual-plane approach, the recently introduced prepectoral approach is gaining popularity.8–12 As a less invasive approach, it shortens operative time, is less traumatic for patients, leads to faster upper limb functional recovery, and eliminates animation deformity and associated pain and discomfort.13–15 Whether these benefits translate to better outcomes for high-BMI patients has not been specifically evaluated. The purpose of this study was thus to compare outcomes after prepectoral and dual-plane reconstruction and to determine whether the plane of reconstruction is a predictor of complications in high-BMI patients.


Study Criteria

This is a retrospective study of patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction in the first author’s practice (A.G.). Dual-plane reconstructions were performed between July of 2009 and August of 2017, and prepectoral reconstructions were performed between June of 2013 and October of 2017. The analytical cohort consisted of consecutive patients with a BMI greater than or equal to 30 kg/m2. Patients who had a BMI less than 30 kg/m2 and patients who underwent direct-to-implant reconstruction, delayed reconstruction, or revision breast surgery were excluded from the analytical cohort. The study was approved by PeaceHealth Southwest Medical Center’s Institutional Review Board (Vancouver, Wash.).

The decision to perform immediate prepectoral or dual-plane reconstruction was made preoperatively after reviewing patient comorbidities and tumor characteristics in oncologic patients with the understanding that the decision to proceed with immediate reconstruction would be dependent on mastectomy flap perfusion. Mastectomy flap perfusion was accessed clinically in patients from the earlier period and with a perfusion assessment device in patients from the later period, when assessment devices became available. In the event of malperfusion, immediate reconstruction was aborted, irrespective of planned reconstructive approach.

During the early part of the study period, a more conservative approach was adopted with regard to selecting patients for prepectoral reconstruction. Patients with a BMI greater than 40 kg/m2 and with comorbidities (diabetes, hypertension, hemoglobin A1c value >7.5 percent, and active smoking), with a history of prior irradiation, who were immunocompromised, and those with certain oncologic criteria (tumors >5 cm, deep tumors, late-stage cancer, chest wall involvement, and grossly positive axillary involvement) were excluded from prepectoral reconstruction.8 Over time, the reconstructive and oncologic exclusion criteria were relaxed. Reconstructive contraindications were restricted to hemoglobin A1c value greater than 7.5 percent and active smoking. Prepectoral reconstruction was offered to patients with diabetes and hypertension if hemoglobin A1c and blood pressure, respectively, were controlled with medication at the time of surgery, irrespective of BMI. The oncologic contraindications for prepectoral reconstruction were restricted to inability to obtain a clear margin, extensive skin involvement, chest wall involvement, and inflammatory breast cancer. Postmastectomy radiotherapy has never been a contraindication for prepectoral reconstruction.

Reconstructive Details

Dual-plane and prepectoral reconstruction were performed, as described previously, with acellular dermal matrix support.16,17 In dual-plane cases, one piece of large (11 × 22 cm) Contour AlloDerm SELECT Regenerative Tissue Matrix (LifeCell Corp., Branchburg, N.J.) was sutured to the edge of the elevated pectoralis major muscle and anchored to the inframammary fold, leaving a 3-cm gutter. In prepectoral cases, depending on the size of the expander, one or two pieces of AlloDerm were used—one 16 × 20-cm piece of AlloDerm Regenerative Tissue Matrix Ready To Use with an additional piece of large Contour AlloDerm, when needed. The majority, if not all, of the expander was wrapped with the dermal matrix before insertion into the prepectoral space.

In both reconstructive approaches, tissue expanders were filled intraoperatively to 70 to 80 percent of capacity, based on the tolerability of the mastectomy flap as assessed with a perfusion assessment device. In prepectoral cases, the expanders were initially filled with air and exchanged for saline during the expansion phase. In dual-plane cases, the expanders were filled with saline. Two drains were placed in the subcutaneous plane before incision closure. Closed negative-pressure therapy was applied to the incision and nipple-areola complex (if nipple-sparing). Before the availability of closed negative-pressure therapy, Steri-Strips (3M, Maplewood, Minn.) were placed over the incision. On postoperative day 3, one drain was removed. The second drain was removed when output was less than 30 cc over 24 hours. On postoperative day 7, negative-pressure therapy was discontinued. Patients were fitted with a compression bra that they wore for 4 weeks. Patients were asked to minimize activity for 4 weeks, with no heavy lifting greater than 5 pounds. Cardiovascular exercise was also discouraged for 4 weeks.

Tissue expansion was commenced 14 to 21 days postoperatively after wound healing. After all drains were removed, prepectoral patients underwent air-to-saline exchange during one or two expansion visits, and the expander was filled to 80 to 90 percent of capacity. Dual-plane patients had saline and underwent one to three expansion visits, and the expander was filled to 80 to 90 percent capacity as well. If adjuvant radiotherapy was indicated, the expander was filled to maximum capacity. Radiation therapy was delivered on fully inflated or partially deflated expanders based on radiation oncologist recommendations. Second-stage implant exchange was performed based on the radiation oncologist’s recommendation but usually approximately 3 to 6 months after completion of radiotherapy. In nonirradiated patients, implant exchange was typically performed at approximately 3 months postoperatively.

Data Collection and Analyses

Data for this study were retrieved from patient records and included demographics (i.e., age and BMI), comorbidities (i.e., smoking status, diabetes, and hypertension), neoadjuvant/adjuvant treatment, type of mastectomy (i.e., skin-sparing or nipple-sparing), mastectomy specimen weight, and postoperative complications following reconstruction (i.e., skin necrosis, seroma, surgical-site infection, prosthesis exposure or loss, return to operating room, and capsular contracture). Surgical-site infection was defined as any sign of cellulitis.

Patients were stratified by reconstructive approach (i.e., dual-plane or prepectoral), and retrieved data were compared between the two groups. Statistical differences between groups were assessed using the Fisher’s exact test for categorical variables and the nonparametric Wilcoxon rank sum test with continuity correction for continuous variables, setting the significance level at below 5 percent. Stepwise multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was a predictor of any complication, adjusting for differences in patient variables between groups. All statistical analyses were performed using the R statistical package.


A total of 133 patients, representing 257 reconstructions, met the inclusion criteria and formed the analytical cohort of the study. Of these patients, 65 (128 reconstructions) underwent dual-plane and 68 (129 reconstructions) underwent prepectoral reconstruction (Table 1). There were no statistically significant differences in patient demographics between the two groups, with mean age and mean BMI being similar. Prepectoral patients had a significantly higher rate of diabetes (39.7 percent versus 10.8 percent) and hypertension (58.8 percent versus 40.0 percent). In the later part of the study period, patients with diabetes and hypertension were increasingly offered prepectoral reconstruction (as long as their comorbidities were controlled and they had well-perfused flaps and no oncologic contraindications), which may explain the higher rates of these comorbidities. Smoking was uncommon in both groups. Adjuvant therapy use was more prevalent among dual-plane patients, with the rate of radiation therapy (10.9 percent versus 1.6 percent) and chemotherapy (30.8 percent versus 5.9 percent) being significantly higher. As patients with oncologic contraindications for prepectoral reconstruction were offered dual-plane reconstruction, this may partly explain the higher rate of adjuvant therapies. With respect to mastectomy parameters, mastectomy specimen weight, rate of skin-sparing mastectomy, and nipple-sparing mastectomy did not differ between the groups.

Table 1. - Demographic, Comorbidity, Neoadjuvant/Adjuvant Therapy, and Reconstructive and Mastectomy Variables Stratified by Reconstructive Approach
Characteristic/Variable Dual-Plane Prepectoral p
No. of patients 65 68 N/A
No. of breasts 128 129 N/A
Age, yr
 Median 53 49
 Range 28.0–73.0 33.0–76.0 0.834
BMI, kg/m2
 Median 33.5 34.0 0.067
 Range 30.0–56.0 30.0–50.0
BMI category
 30.0–34.9 kg/m2 66.7% 57.4%
 35.0–39.9 kg/m2 18.2% 23.5%
 ≥40.0 kg/m2 15.2% 19.1%
No. of smokers 3 (4.6%) 3 (4.4%) 1.00
No. of diabetics 7 (10.8%) 27 (39.7%) 0.0001*
No. of patients with hypertension 26 (40.0%) 40 (58.8%) 0.038*
No. of patients receiving radiation therapy 18 (14.1%) 7 (5.4%) 0.021*
 Preoperative 4 (3.1%) 5 (3.9%) 1.00
 Postoperative 14 (10.9%) 2 (1.6%) 0.002*
No. of patients receiving chemotherapy 28 (43.1%) 13 (10.3%) 0.005*
 Preoperative 8 (12.3%) 9 (13.2%) 1.00
 Postoperative 20 (30.8%) 4 (5.9%) 0.0002*
No. of breasts undergoing each type of mastectomy
 Skin-sparing 101 (78.9%) 106 (82.2%) 0.532
 Nipple-sparing 25 (19.5%) 21 (16.3%) 0.519
 Not reported 2 (1.6%) 2 (1.6%) 1.00
Mastectomy specimen weight, g
 Median 731.3 805.0 0.164
 Range 322.0–1500.0 148.0–1805.0
N/A, not applicable.
*Statistically significant.

Postoperative complications were generally higher in dual-plane patients (Table 2), with rate of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) being significantly higher. There were no statistical differences in the rate of skin necrosis, wound dehiscence, expander/implant exposure or loss, or return to operating room. Eleven reconstructions (8.6 percent) in eight dual-plane patients were converted to prepectoral reconstruction, and there were no conversions from prepectoral to dual-plane.

Table 2. - Complications Stratified by Reconstructive Approach
Dual- Plane (%) Prepectoral (%) p
No. 128 129
Complication type
 Skin necrosis 17 (13.3) 15 (11.6) 0.710
 Seroma 17 (13.3) 4 (3.1) 0.003*
 Surgical-site infection 12 (9.4) 3 (2.3) 0.018*
 Wound dehiscence 12 (9.4) 9 (7.0) 0.505
 Expander/implant exposure 6 (4.7) 3 (2.3) 0.334
 Return to operating room 15 (11.7) 10 (7.8) 0.301
 Expander/implant loss 2 (1.6) 2 (1.6) 1.000
 Capsular contracture 9 (7.0) 1 (0.8) 0.019*
 Any complication 33 (25.8) 19 (14.7) 0.030*
*Statistically significant.

On average, dual-plane patients were followed for a longer period: 24.1 ± 2.0 months versus 22.7 ± 3.5 months for prepectoral patients (p = 0.005). All reported postoperative complications in both groups, however, occurred within the first 18 months following completion of reconstruction.

To determine the effect of the plane of reconstruction on the rate of any complication and eliminate the effect of potential confounding variables that were unevenly distributed between the dual-plane and prepectoral groups, a stepwise multivariate logistic regression was performed. Before the multivariate analysis, a univariate analysis was performed to identify binary variables that were significant predictors of any complication. The purpose of this step was to eliminate binary variables that were not significantly associated with the development of any complication from being tested in the multivariate model to reduce the noise and eliminate the danger of overfitting the model.

The univariate analysis identified dual-plane reconstruction, diabetes, neoadjuvant and adjuvant radiotherapy, and adjuvant chemotherapy as significant predictors of any complication (Table 3). These variables, together with the continuous variables age, BMI, and mastectomy specimen weight, were included in the stepwise multivariate logistic regression model. The model identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant independent predictors of any complication (Table 4). The odds of any complication were increased by approximately 6.2-fold in patients with diabetes, 5.9-fold in patients with neoadjuvant radiotherapy, 3.7-fold in patients with adjuvant chemotherapy, and 3.0-fold in patients who underwent dual-plane reconstruction. In addition, adjuvant radiotherapy increased the odds of any complication by 2.3-fold, although the increase was not statistically significant.

Table 3. - Univariate Analysis of Categorical Variables Associated with Any Complication
Variable Any Complication Events (%) OR (95% CI) p
Plane of reconstruction: dual-plane
 Yes 25.8 2.01 (1.07–3.77) 0.029*
 No 14.7
 Yes 33.3 2.05 (0.59–7.10) 0.256
 No 19.6
 Yes 33.8 2.76 (1.45–5.26) 0.002*
 No 15.6
 Yes 20.6 1.05 (0.57–1.93) 0.875
 No 19.8
Preoperative radiotherapy
 Yes 55.6 5.35 (1.38–20.67) 0.015*
 No 19.0
Postoperative radiotherapy
 Yes 50.0 4.50 (1.60–12.64) 0.004*
 No 18.2
Preoperative chemotherapy
 Yes 21.1 1.07 (0.44–2.62) 0.881
 No 20.1
Postoperative chemotherapy
 Yes 44.7 4.66 (2.34–9.30) <0.0001*
 No 14.8
Skin-sparing mastectomy
 Yes 20.3 1.02 (0.47–2.20) 0.964
 No 20.4
*Statistically significant.

Table 4. - Multivariate Logistic Regression Analysis: Risk Factors for Any Complication
Risk Factor OR (95% CI) p
Dual-plane 3.04 (1.30–7.61) 0.013*
Diabetes 6.24 (2.71–15.46) <0.001*
Preoperative radiotherapy 5.92 (1.29–28.78) 0.021*
Postoperative chemotherapy 3.70 (1.66–8.36) 0.001*
Age 0.97 (0.94–1.00) 0.077
BMI 0.93 (0.83–1.04) 0.208
Postoperative radiotherapy 2.28 (0.66–7.80) 0.188
Mastectomy specimen weight 1.00 (0.999–1.001) 0.936
*Statistically significant.


It is well established that high-BMI patients have poorer outcomes after breast reconstructive surgery compared with normal-weight patients.1–4 Furthermore, BMI has been shown to be an independent predictor of postoperative complications after dual-plane reconstruction.6 However, in patients undergoing prepectoral reconstruction, the authors have found that BMI does not appear to predict complications.18 Furthermore, the authors’ preliminary data in a small cohort of high-BMI patients suggested that these patients appeared to have similar to better outcomes with the prepectoral approach compared with their historical data with the dual-plane approach.17 An in-depth comparative analysis was thus performed in this study to assess whether the plane of reconstruction influences complications in high-BMI patients.

The results suggest that there are significant differences in certain complications between the two approaches. The rate of seroma, surgical-site infection, and capsular contracture were significantly elevated in dual-plane patients, which in part may be attributed to the higher rates of adjuvant therapies used in these patients. Indeed, multivariate logistic regression identified adjuvant chemotherapy as a significant independent predictor of complications. In addition, the plane of reconstruction may, in part, contribute to the elevated rate of complications. Compared with the prepectoral plane, the dual-plane approach significantly increased the odds of any complication by 3-fold after accounting for potential confounding variables in a stepwise multivariate logistic regression model.

How can the dual-plane approach potentially contribute to an increased risk of complications in high-BMI patients? Elevating the pectoralis muscle is an additional procedure that is obviated in the prepectoral procedure. Any additional procedure can increase the potential for contamination and thus the potential for surgical-site infections. The higher rate of seroma with the dual-plane approach in high-BMI patients may be attributed to the shearing of the pectoralis muscle–acellular matrix interface against the mastectomy flap.17 High-BMI patients tend to use their upper body, instead of core body strength, to lift themselves from a sitting to a standing position. The shearing caused by repeated use of the pectoralis muscle for this maneuver in the immediate postoperative period could result in seroma formation. The higher rate of capsular contracture in the dual-plane approach is likely attributable to partial coverage of the prosthesis with acellular dermal matrix as opposed to complete anterior coverage with the matrix in the prepectoral approach. It is well established that acellular matrix mitigates the risk of capsular contracture19,20 by inhibiting the inflammatory and profibrotic signaling, resulting in thinner capsules.21,22 Capsule formation, however, can still occur over the area not covered by acellular dermis in the dual-plane approach.

From an aesthetic perspective, the prepectoral approach may also result in more natural-appearing breasts (Figs. 1 through 3) than the dual-plane approach in high-BMI patients. High-BMI patients have large breasts and thus a large subcutaneous space. The subpectoral space, however, is limited and the ratio of subpectoral to subcutaneous space is smaller in large- versus small-breasted women. The limited subpectoral space restricts the extent of expansion of the expander placed subpectorally, while placing the expander subcutaneously or prepectorally allows for greater expansion. The muscle also restricts some of the projection of the implant. Thus, larger and higher projecting implants are required in dual-plane cases to achieve a better projection. Conversely, muscle restriction on the implant is eliminated with placement of an implant in the subcutaneous space, and therefore smaller and less projecting implants can be placed in prepectoral patients. It should be noted that aesthetic outcomes and volume of breast implants placed were not evaluated in this study, and the above perspectives are based on the authors’ observation and clinical experience.

Fig. 1.
Fig. 1.:
A 60-year-old woman with a BMI of 31.0 kg/m2 and left breast cancer. She underwent bilateral skin-reducing mastectomy followed by immediate prepectoral expander/implant reconstruction. (Above) Preoperative views. (Center) Postoperative day 7 following expander placement. (Below) At 28 months after implant exchange and fat grafting.
Fig. 2.
Fig. 2.:
A 51-year-old woman with a BMI of 35.5 kg/m2 and left breast cancer. She underwent bilateral skin-sparing mastectomy followed by immediate prepectoral expander/implant reconstruction. (Above) Preoperative views. (Below) At 26 months after implant exchange and fat grafting.
Fig. 3.
Fig. 3.:
A 50-year-old woman with a BMI of 42.5 kg/m2 and left breast cancer. She underwent bilateral skin-reducing mastectomy followed by immediate prepectoral expander/implant reconstruction. (Above) Preoperative views. (Below) At 27 months after implant exchange and fat grafting.

It should be emphasized that the plane of reconstruction is one of several independent predictors of any complication in this series. Diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy were the other significant, independent predictors of any complication. Diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy are well-established risk factors for complications after subpectoral prosthetic reconstruction.23–28 The current results suggest that they are also independent risk factors for complication after prepectoral reconstruction. Patients with diabetes are offered immediate prepectoral reconstruction only if their hemoglobin A1c value is less than 7.5 percent.8 The results also suggest that even if diabetes were to be controlled, the risk of complications associated with diabetes persists.

This study is limited by its relatively small sample size and its retrospective nature. In addition, the higher rates of adjuvant therapy in the dual-plane group may have confounded the results, although multivariate logistic regression was used to account for the difference. Future studies will explore differences in aesthetic benefits between the prepectoral and the dual-plane approaches.


In high-BMI patients undergoing immediate expander/implant breast reconstruction, the dual-plane approach, in addition to diabetes, adjuvant chemotherapy, and neoadjuvant radiotherapy, appears to be a significant, independent predictor of postoperative complications. The prepectoral approach appears to have a lower risk of postoperative complications and may be a better reconstructive option in these patients.


Writing and editorial assistance was provided by Kalanethee Paul-Pletzer, Ph.D., and data analysis was provided by Vadim A. Pletzer.


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