Implant-Based Breast Reconstruction After Nipple-Sparing and Skin-Sparing Mastectomy in Breast-Augmented Patients: Prepectoral or Submuscular Direct-to-Implant Reconstruction?

Abstract

Patients with breast augmentation facing a breast cancer diagnosis pose unique challenges for both breast and plastic surgeons in terms of treatment and reconstruction. Traditional submuscular direct-to-implant (DTI) breast reconstruction is often considered the standard approach, regardless of the previous implant pocket. However, recent trends in prepectoral reconstruction provide an innovative solution for patients with previous subglandular and submuscular implants. In this study we aimed to share our experiences with DTI breast reconstruction in patients with a history of breast augmentation, with a specific focus on the viability of prepectoral reconstruction. A retrospective review was conducted on 38 patients with previous breast augmentation who underwent either skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer followed by DTI reconstruction between January 2015 and July 2023. Our analysis considered various factors, including previous implant positioning, capsular and implant status, and mastectomy flap thickness (MFT), offering insights into the rationale behind choosing the new implant positioning. Patients with a history of subglandular breast augmentation and an MFT greater than 1 cm were candidates for prepectoral reconstruction. When the MFT was less than 1 cm but flap vascularity was sufficient, a prepectoral reconstruction was performed; otherwise, retropectoral reconstruction was preferred. Patients with submuscular breast augmentation were evaluated similarly, with submuscular reconstruction chosen when the MFT was less than 1 cm and prepectoral reconstruction preferred when the MFT exceeded 1 cm. Immediate prepectoral DTI reconstruction represents a feasible option for specific patients with a history of breast augmentation. Decisions regarding the reconstructive approach are influenced by variables such as mastectomy flap thickness, implant status, and capsular conditions.