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Submuscular versus Prepectoral Immediate Implant Based Breast Reconstruction
Karan Chopra, MD1, Carrie Houssock, MD1, Stephen S. Cai, BS2, Cynthia L. Drogula, MD2, Roberta Lily, MD2, Arvind Gowda, MD3, Nelson Goldberg, MD2.
1Johns Hopkins Hospital, University of Maryland, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA, 3Yale School of Medicine, New Haven, CT, USA.

Background: Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix(ADM) is a popular method for breast reconstruction. Subpectoral placement of the implant is often favored and usually results in a desirable cosmetic outcome. However, drawbacks of subpectoral placement include greater postoperative pain and animation deformities. The authors report their experience with single-stage direct-to-implant breast reconstruction with prosthetic placement in both the prepectoral plane and the subpectoral plane.
Methods: A retrospective review of a single surgeons experience was performed for immediate single-stage implant reconstruction with ADM between 2011 and 2015. Statistical analysis was performed to evaluate differences between the subpectoral versus prepectoral group and the association between pre-operative characteristics and post-operative complications. All tests were two-tailed with a significance level of p< 0.05.
Results: The study sample consisted of 38 subjects representing reconstruction of 61 breasts(41 subpectoral and 20 prepectoral). With the exception of body mass index(24.8±4.9 subpectoral vs. 35.9±8.6 prepectoral, p<0.01), pre-operative characteristics were statistically similar between the subpectoral and prepectoral group including age, smoking, diabetes, prior breast surgery, and radiation and/or chemotherapy(Table 1). The prepectoral group tended to receive larger implants(p<0.01), but the type of mastectomy, type of nodal exploration, and blood loss did not differ significantly between the two groups(Table 2). At the median follow-up of 283 days, the overall rate of complications between the subpectoral and prepectoral group were similar. Specific complications including 30-day readmission, dehiscence, infection, mastectomy skin flap necrosis, and seroma were statistically comparable between the two groups(Table 3), while the incidence of capsular contracture was significantly higher in the subpectoral group (17.1% vs. 0%; p=0.049). In this cohort, prior breast surgery was associated with a higher rate of dehiscence and necrosis, while capsular contracture was associated with adjuvant chemotherapy (Table 4).
Conclusion: The present study demonstrates that immediate prepectoral reconstruction can be performed with results that are non-inferior to the traditional subpectoral approach in terms of post-operative complications and may offer the cosmetic benefits of prepectoral placement. The rate of capsular contracture was in fact lower in the prepectoral group. A larger cohort is needed to corroborate the present conclusions.
Table 1: Pre-operative Characteristics
All PatientsPrepectoral
Number of cases382513
Number of breasts614120
Age (y, )51.9±14.151.3±10.953.1±19.20.771
BMI (kg/m^2, )28.6±8.224.8±4.935.9±8.6<0.01
Smoking (%)14 (36.8)7 (28.0)7 (53.9)0.117
Diabetes mellitus (%)4 (10.5)3 (12.0)1 (7.7)0.681
Prior breast surgery (%)7 (18.4)4 (16.0)3 (23.1)0.593
Radiation (%)
Neoadjuvant1 (2.6)1 (4.0)0 (0)0.465
Adjuvant6 (15.8)4 (16.0)2 (15.4)0.961
Chemotherapy (%)
Neoadjuvant10 (26.3)6 (24.0)4 (30.8)0.653
Adjuvant6 (15.8)5 (20.0)1 (7.7)0.324

Table 2: Operative Characteristics
All PatientsSubpectoral
Indication (%)
Prophylactic7 (18.4)5 (20.0)2 (15.4)
Breast cancer31 (81.6)20 (80.0)11 (84.6)0.728
Type of mastectomy (%)
Nipple sparing8 (21.1)6 (24.0)2 (15.4)
Simple27 (71.0)16 (64.0)11 (84.6)
Modified3 (7.9)3 (12.0)0 (0)0.305
Side (%)
Unilateral15 (39.5)9 (36.0)6 (46.2)
Bilateral23 (60.5)16 (64.0)7 (53.8)0.545
Node (%)
Sentinal node biopsy25 (65.8)16 (64.0)9 (69.2)
Sentinal node dissection4 (10.5)4 (16.0)0 (0)0.282
Estimated blood loss
(ml, )
Implant size
(ml, )
Soft tissue support (%)
Alloderm35 (92.1)25 (100)10 (76.9)
Autoderm3 (7.1)0 (0)3 (23.1)0.012

Table 3: Postoperative Outcome Data
All PatientsSubpectoral
Days of follow-up
283 (140, 589)397 (193, 644)161 (208, 229)0.031
Readmission within 30 days (%)6 (15.8)4 (16.0)2 (15.4)0.961
Incidence of complications
(% per breast)
13 (21.3)10 (24.4)3 (15.0)0.401
Dehiscence2 (3.3)1 (2.4)1 (5.0)0.598
Infection4 (6.6)3 (7.3)1 (5.0)0.731
Necrosis3 (4.9)2 (4.9)1 (5.0)0.984
Seroma4 (6.6)2 (4.9)2 (10.0)0.448
Capsular contracture7 (11.5)7 (17.1)0 (0)0.049
Complication requiring explantation or exchange (%)12 (19.7)9 (21.9)3 (15.0)0.521

Table 4: Association of Pre-operative Characteristics and Postoperative Complication by p-values
All-cause ComplicationsDehiscenceInfectionNecrosisSeromaCapsular Contracture
Prior breast surgery0.1570.0300.3150.0250.0850.443

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