Animation deformity (AD), including its prevalence and effect on patients, has been studied in the context of subpectoral augmentation mammaplasty.1 However, to our knowledge, only 1 other study has defined the prevalence and effect of AD in the subpectoral implant-based breast reconstruction patient population.2 Given the recent rise in prepectoral, implant-based reconstruction, an assessment of patient experience with AD in the partial subpectoral implant-based reconstruction population is timely and relevant.
This study was approved by the Virginia Commonwealth University Institutional Review Board. Patients included in the study were reconstructed using a tissue expander and perforated, crescent-shaped acellular dermal matrix (ADM) in the lower pole for the first stage, followed by replacement with a silicone implant 2–3 months later, or direct-to-implant using ADM in the same position. In general, in larger breasted reconstructions, more of the pectoralis muscle was detached and a larger proportion of ADM was used to recreate the inferior pole. The senior author performed all procedures (N.B.).
A questionnaire was mailed to all patients who had undergone subpectoral, implant-based breast reconstruction with ADM from January 1, 2012, to March 30, 2016 (see document, Supplemental Digital Content 1, which displays the postmastectomy reconstruction questionnaire, http://links.lww.com/PRSGO/A477). This was distributed during breast cancer awareness month and was presented to patients as a study that could potentially help future mastectomy patients. Patients were asked if they notice AD, which was defined as a “twitching or movement of the upper portion of the breast with certain muscle movements of the arms or chest” and if so, how bothersome they found it on a scale of 1–10 (1 being not at all, 10 being disabling). They were then asked their level of athleticism with the same scale (1 being not athletic, 10 being extremely athletic). Lastly, they were asked their interest in an initial alternative procedure that would have eliminated AD and whether they would still have been interested if the procedure involved increased risk, cost, or additional fat grafting procedures. Patients were provided prestamped envelopes for returning the questionnaires. Data recorded included patient age, preoperative and most recent BMI, and implant size. All returned questionnaires were compiled, and data were analyzed using SAS 9.4 (SAS Institue Inc., Cary, N.C.). When patients had bilateral implants, the larger of the 2 implant sizes was used for analysis. Our scale for gauging degree of AD, from 1–10, was converted to the categories none, minimal, mild, moderate, and severe for comparison with Spear’s breast augmentation cohort (Fig. 1).1 All tests were 2-tailed tested and used a significance level of 0.05. Due to the nonnormal distribution of the continuous variables, the nonparametric tests, Spearman correlation, and Wilcoxon 2-sample rank sum test, were used for the analyses. Categorical variables were compared using Fisher’s exact test.
One hundred eight patients were identified by chart review and mailed questionnaires. Eighty-four returned the questionnaire for a response rate of 77.8%; however, 1 patient was not included in data analysis as her implant had been explanted before the study, and every patient did not answer every question. All patients were at least 6 months postoperative extending up to 6 years postoperative. Patient characteristics are shown in Table 1.
Twenty of 82 patients (24.4%) were unaware of AD, 41 (50.0%) considered it minimal or mild, 12 (14.6%) considered it moderate, and 9 (11.0%) considered it severe (Fig. 1). The degree of AD is significantly higher than the degree of AD found by Spear et al.1 in breast augmentation (P = 0.0051, Fisher’s exact test; Fig. 1).
Patient age, BMI, implant size, and level of perceived athleticism did not significantly differ between those who noted AD and those who did not (Table 2). In those who noted AD, there was a small, negative correlation between preoperative/recent BMI and the degree of AD (−0.12953/−0.10188) in which the lower the BMI the more noticeable the AD; similarly, there was a negative correlation between implant size and the degree of AD (−0.11812; Spearman correlation coefficients). These correlations were not statistically significant.
Forty-one of 79 patients (51.9%) would have been interested in an alternative surgical procedure to avoid AD at the time of the original mastectomy. If the procedure involved additional fat grafting, interest dropped to 50%; if it involved increased cost, interest dropped to 34.1%; if it involved increased risk, interest dropped to 8.9% (Fig. 2).
AD, also referred to as dynamic breast deformity or dynamic distortion, describes the perceived unnatural or exaggerated movement of the pectoralis muscle and/or subjacent implant with pectoralis contraction. This may not only be unsightly and embarrassing for the breast reconstruction patient but may also cause discomfort with certain activities; in more extreme cases, AD can be emotionally and physically debilitating.2 Although Spear et al.1 found that 53% of patients note AD after submuscular breast augmentation, we found this number to be notably higher in the breast reconstruction population (75.6%). This difference would be anticipated due to the absence of the breast parenchyma to camouflage the deformity, as well as the probability of more aggressive muscle separation inferomedially to accommodate generally larger breast reconstruction implants. Compared with the recent study by Becker and Fregosi2, our patients were slightly less aware of AD (75.6% versus 80%). Whereas Becker and Fregosi2 found that 36% of patients experienced severe AD, 11% of ours experienced severe AD. Perhaps, this is due to Becker and Fregosi’s2 relatively small sample size, potential differences in severity scales, or that 28% of their patients were scheduled for revisions and perhaps self-selected.
We anticipated that more athletic patients, likely being more active and more muscular, would be more bothered by AD. Although there was a small difference, it was not statistically significant. We felt that BMI might correlate with AD anticipating that thinner patients with less fat grafting available would be more affected, or that larger patients with larger implants would have exaggerated AD as more muscle was detached to accommodate a larger implant. None of these hypotheses proved to be correct.
Methods to reduce AD, in both augmentation and reconstruction, have been explored. These include pectoralis muscle splitting or sectioning techniques and chemical or mechanical muscle denervation.3–7 With the advantages of ADM and fat grafting, prepectoral breast reconstruction is being performed with increased frequency.8–15 Subcutaneous implant-based breast reconstruction was popular in the early 1980s but was largely abandoned and replaced with submuscular implant-based breast reconstruction because of the concerns for implant visibility, palpability, malposition, encapsulation, rippling, extrusion, infection, and wound healing issues.16 With the relatively recent advent of ADM for anterior coverage of prostheses, and reliable fat grafting, prepectoral breast reconstruction has been revisited with the advantages of elimination of AD as well as shorter operative times and easier postoperative recovery.17 Acceptable encapsulation, infection, and flap necrosis rates have been reported.14 Understanding of the disadvantages of this new generation of subcutaneous implant-based breast reconstruction is evolving. Oncologic surgeons may not be comfortable with thicker, more robust mastectomy flaps, which are ideal for prepectoral reconstruction. Perfusion systems that guide intraoperative decisions have been advocated but may not always be available.18 Implant visibility and rippling remains an issue that can be ameliorated but perhaps not always eliminated by fat grafting, despite more cohesive implants. Stability of the footprint of the reconstruction may be more problematic as it depends entirely on stabilization of the ADM pocket on the chest wall and may prove to be an issue with larger implants. The issue of increased cost should not be ignored; covering the implant with ADM can incur tens of thousands of dollars of increased cost, which although currently covered by most insurance policies, does ultimately contribute to overall health-care costs of mastectomy patients. Minor wounds need to be excised early as the skin buttressed only by ADM may not heal as readily as more robust flaps.15 It remains to be seen whether these flaps will remain more prone to skin injury, wound healing problems, or radiation injury. As with autologous reconstruction, the footprint of the original breast is now covered by the reconstruction, so chest wall recurrences will be harder to detect. Finally, as this is a relatively new procedure, we do not have long-term follow-up studies.
Although the patient population was drawn from a single surgeon’s practice, we believe this eliminated variation in surgical technique as a variable when assessing patients’ experience with AD. We attribute our high response rate (77.8 %) to heightened patient motivation to help other patients who have undergone mastectomy and reconstruction during October, which is breast cancer awareness month. We recommend that future questionnaire-based studies use similar timing. Despite this high response rate, it is possible that our study lacked the power to show statistically significant differences between those who noted AD and those who did not. Several other limitations should be noted: we did not take into account whether patients underwent radiation and how this may have affected AD. We did not address timing as a variable; perhaps AD improves or worsens with time. We lack objective data from nonself observers, although we postulate that since this is a quality of life issue, the patient’s self-perception is actually more important than the opinion of outside observers. We failed to ask our patients about pain, as this is another reported disadvantage of subpectoral breast reconstruction. Cost as a variable was not qualified in terms of personal cost or increased health-care cost in general so this metric in our survey is unfortunately of limited value. Lastly, as with any questionnaire-based study, there is inherent sampling bias. Despite these limitations, this study presents the prevalence and severity of AD in a group of 84 patients and the extent to which patients may be willing to make compromises to avoid it.
As anticipated, the prevalence of AD in subpectoral implant-based breast reconstruction is higher than in subpectoral breast augmentation. We found small, albeit insignificant, differences in age, BMI, implant size, and athleticism between patients who note AD and those who do not. Although approximately half of patients would have been potentially interested in an initial procedure that reduces AD, they were much less interested if this involved increased risk, cost, or additional surgeries. Therefore, although AD is quite debilitating for some patients, we did not find an overwhelming mandate among our patients for a complete reimagination of implant-based breast reconstruction. We are not arguing against prepectoral breast reconstruction, which is an exciting new innovation, but would like to place AD in a patient-centered context. It may be an issue that is more disturbing to us as surgeons than it is to our patients. Unfortunately, we were unable to determine which patients are at highest risk for AD, and future studies are needed in this area. Patients should be aware of the advantages and disadvantages of each technique as our knowledge evolves so that they may make informed choices.
We would like to acknowledge Dawn Sykes, Luke Wolfe, MS, and Maryann Martinovic, MD, for their assistance with data collection, statistical analysis, and editing.
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