The patient sample of this study was highly selected and consists largely of healthy women requesting prophylactic NSM and DIR, an optimal group of patients to test technical refinements and minimize possible confounders at the same time. We have previously published our experience regarding the importance of patient selection and how to overcome the challenge of large and ptotic breasts to make the mastectomy and DIR as safe as possible.19–21
We notice that patients reconstructed by this simple single sheet prepectoral DIR technique seem to experience no breast animation deformity, less postoperative pain, shorter time with drains, and quicker recovery and good cosmetic outcomes, which is in accordance with recently published reports of similar muscle sparing or prepectoral implant-based reconstructions.11,14–17 One down side is a risk of developing implant visibility over time, particularly in patients with low BMI, which we have observed in 4 (15%) patients so far. Similar findings have been reported by Lee et al.22 in 2012 and Sbitany et al.15 in 2017.
Long-term experience from breast augmentation indicates that there is a 2-fold increase in the risk of visible capsular contraction with subglandular compared with submuscular breast implant location.23 This may also turn out to be the case following breast reconstruction; however, we cannot expect to be able to answer the question regarding the risk of developing capsular contracture any time soon as the cumulative risk peaks after 5 years.24
Although the existing literature largely supports the advantage of a total coverage of the implant using a biologic acellular matrix sheet,, this 1 year follow-up seems to indicate a satisfying outcome despite only a partial coverage.11,14–17
There are still many unanswered questions regarding the use of mesh for breast reconstruction and where to place the implant for optimal results. One important question is if the aesthetic results will be comparable with other reconstructive methods in the long run? This, however, requires comparative studies with a longer follow-up.
The partial implant coverage using a prepectoral inferolateral hammock technique is a simple, fast, and reliable method of DIR. The patients seem to experience less postoperative pain, shorter time with drains, and quicker recovery than we have experienced following the dual-plane DIR. The cosmetic outcomes seem to be just as favorable as other types of DIR that we have used over time. Patient selection is important as the thickness of the mastectomy flaps and comorbidity does play an important role for the successful outcome. Further studies and longer follow-up are required to compare long-term risks of capsular contracture, implant visibility, and the significance of different degrees of mesh coverage of the implant in different types of immediate breast reconstructive techniques.
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