Picking the Right Plane: A Comparison of Total Submuscular, Dual-plane, and Prepectoral Implant-based Breast Reconstruction
Ara A. Salibian, MD, Jonathan M. Bekisz, MD, Jordan D. Frey, MD, Mihye Choi, MD, Nolan S. Karp, MD.
NYU Langone Health, New York, NY, USA.
Background:
Positioning of implant placement in breast reconstruction has evolved over time with a resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been fully elucidated among the three most common planes of implant placement: total submuscular (TSM), dual-plane and prepectoral.
Methods:
A retrospective chart review was performed of all immediate implant-based breast reconstruction at a single institution from 2017-2019. Cases were divided into total TSM, dual-plane and prepectoral cohorts. Patient demographics, operative techniques and reconstructive complications were analyzed and compared among groups.
Results:
A total of 608 cases (374 patients) were identified and divided into total submuscular (289 cases), dual-plane (264 cases) and prepectoral (55 cases) cohorts (Table 1). Average follow-up was 13 months. Patients in the prepectoral cohort had a higher average BMI (28) compared to TSM (24.6) and dual-plane (25.3) patients (p<0.0001), and a higher rate of prior reduction (9.1%, p=0.028). Otherwise there were no significant differences in patient demographics and preoperative risk factors among the three cohorts.
The dual-plane cohort had a higher rate of prophylactic mastectomy (48.9%) compared to TSM (39.9%, p=0.034) and prepectoral (32.7%, p=0.029) cases. Rates of immediate implant reconstruction were also higher in dual-plane (35.2%) and prepectoral (23.6%) cohorts compared to TSM reconstruction (0%, p<0.0001). Use of ADM/mesh was similarly higher in dual-plane and prepectoral cohorts (p<0.0001). Initial tissue expander fill was significantly higher in the dual-plane (205.3 cc) and prepectoral (209.5 cc) cases compared to TSM reconstructions (94 cc, p<0.0001).
Complication rates were comparable among all three planes of reconstruction including major ischemic complications and infection, with the exception of isolated incisional dehiscence which was higher in the dual-plane (4.2%, p=0.002) and prepectoral (3.6%, p=0.016) cohorts. The explantation rate trended higher in the prepectoral cohort (7.3%) but was not statistically significant.
Conclusions:
Patients undergoing implant-based breast reconstruction had similar demographics and preoperative risk factors among the three planes of implant placement suggesting that patient goals and intraoperative factors such as mastectomy flap quality may play a larger role in decisions-making among TSM, dual-plane or prepectoral positioning.
Reconstructive complication rates were overall favorable and comparable among TSM, dual-plane and prepectoral cohorts with the exception of a higher rate of isolated dehiscence in the latter two groups. Explantation rates trended high in the prepectoral group, suggesting an inherent inability to tolerate complications with this plane of implant placement though further research is needed to clarify these observations.
| Table 1. Comparison of patient demographics, operative characteristics and reconstructive outcomes among immediate total submuscular, dual-plane and prepectoral implant-based breast reconstruction | |||
| Total Submuscular | Dual-Plane | Prepectoral | |
| Patient Demographics | |||
| Breasts | 289 | 264 | 55 |
| Patients | 181 | 155 | 38 |
| Age (years) | 49.6 | 49.2 | 52 |
| BMI (kg/m2) | 24.6 | 25.3 | 28 |
| Diabetes Mellitus | 15 (5.3%) | 8 (3.1%) | 2 (3.6%) |
| Tobacco Use | |||
| Active | 13 (3.5%) | 11 (4.2%) | 0 |
| Former | 84 (28.5%) | 67 (25.6%) | 15 (27.3%) |
| Prior Breast Augmentation | 12 (4.2%) | 9 (3.4%) | 1 (1.8%) |
| Prior Breast Reduction | 12 (4.2% | 5 (1.9%) | 5 (9.1%) |
| Previous Radiation | 19 (6.7%) | 9 (3.4%) | 4 (7.3%) |
| Previous Chemotherapy | 58 (20.4%) | 36 (13.8%) | 11 (20%) |
| Postoperative Radiation | 42 (15.1%) | 36 (14.1%) | 10 (18.5%) |
| Postoperative Chemotherapy | 75 (26.6%) | 61 (23.6%) | 14 (25.5%) |
| Bilateral | 216 (74.7%) | 219 (83%) | 34 (61.8%) |
| Oncologic Characteristics | |||
| Mastectomy Indication | |||
| Therapeutic | 172 (60.1%) | 135 (51.1%) | 37 (67.3%) |
| Prophylactic | 114 (39.9%) | 129 (48.9%) | 18 (32.7%) |
| Mastectomy Type | |||
| MRM | 2 (0.7%) | 3 (1.1%) | 0 |
| Total | 163 (54.7%) | 86 (32.2%) | 30 (54.5%) |
| SSM | 57 (19.1%) | 36 (13.5%) | 8 (14.5%) |
| NSM | 76 (25.5%) | 142 (53.2%) | 17 (30.9%) |
| Mastectomy Weight (grams) | 476.1 | 565 | 545 |
| Reconstructive Techniques | |||
| Reconstructive Modality | |||
| TE | 298 (100%) | 173 (64.8%) | 42 (76.4%) |
| Immediate Implant | 0 | 94 (35.2%) | 13 (23.6%) |
| Biologic or Synthetic Reinforcement | |||
| ADM | 0 | 208 (78.8%) | 30 (54.5%) |
| Mesh | 0 | 37 (14%) | 0 |
| Initial TE fill (cc) | 94 | 205.3 | 209.5 |
| Reconstructive Outcomes | |||
| Time to implant exchange (months) | 5.4 | 6.1 | 5.7 |
| Complications | |||
| Minor MF Necrosis | 13 (4.6%) | 9 (3.5%) | 5 (9.1%) |
| Major MF Necrosis | 13 (4.6%) | 14 (5.4%) | 1 (1.8%) |
| Partial NAC necrosis | 13 (16.5%) | 9 (7%) | 0 (0%) |
| Full NAC necrosis | 4 (5.1%) | 3 (2.3%) | 0 (0%) |
| Isolated incisional dehiscence | 1 (0.3%) | 11 (4.2%) | 2 (3.6%) |
| Minor Infection | 12 (4.2%) | 12 (4.6%) | 1 (1.8%) |
| Major Infection | 3 (1.1%) | 8 (3.1%) | 3 (5.5%) |
| Seroma | 3 (1%) | 10 (3.8%) | 2 (3.6%) |
| Hematoma | 6 (2.1%) | 2 (0.8%) | 0 |
| Implant Exchange | 1 (0.3%) | 5 (1.9%) | 1 (1.8%) |
| Explantation | 6 (2.1%) | 12 (4.5%) | 4 (7.3%) |
| Follow-up Length (mo) | 13.6 | 13.1 | 9.6 |
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