Animation Deformity Research Articles

Evaluation of Breast Animation Deformity following Pre- and Subpectoral Direct-to-Implant Breast Reconstruction: A Randomized Controlled Trial.

Background The incidence of breast animation deformity (BAD) is reported to be substantial after direct-to-implant breast reconstruction with subpectoral implant placement. It has, however, never been examined if BAD can occur following prepectoral implant placement. Our primary aim was to compare the incidence and degree of BAD after direct-to-implant breast reconstruction using either subpectoral or prepectoral implant placement. Secondary aim of this study was to assess and compare the level of pain between sub- and prepectoral reconstructed women. Methods In this randomized controlled trial, patients were allocated to reconstruction by either subpectoral or prepectoral implant placement in accordance with the CONSORT guidelines. The degree of BAD was assessed by the “Nipple, Surrounding skin, Entire breast (NSE)” grading scale 12 months after surgery. The level of postoperative pain was assessed on a numerical pain rating scale. Results We found a significant difference in the degree of BAD favoring patients in the prepectoral group (23.8 vs. 100%, p < 0.0001; mean NSE grading scale score: 0.4 vs. 3.6, p < 0.0001). The subpectoral reconstructed group reported higher levels of pain on the three subsequent days after surgery. No significant difference in pain levels could be found at 3 months postoperatively. Conclusion The incidence and degree of BAD was significantly lower in women reconstructed by prepectoral direct-to-implant breast reconstruction. Unexpectedly, we found mild degrees of BAD in the prepectoral group. When assessing BAD, distortion can be challenging to discern from rippling.

Pectoral Muscle Re-Attachment with Breast Implant Removal

Breast implant removal is an increasingly requested procedure. An uncommon but important reason for this is breast animation deformity (BAD). Although methods such as the split muscle have been used for prevention and correction of animation deformity successfully for many years, [1, 2] we occasionally see patients who have undergone explantation and present with unresolved animation. These patients have had prior unsuccessful attempts at correction by further muscle release, and explantation was done as a final attempt at resolution. We regard muscle re-attachment as key to correction of animation. Herein we present illustrative cases and discuss technical points.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

Prepectoral implant reconstruction + ADM as a method for revision surgery

Introduction: Prepectoral reconstruction has been used in Manchester to correct animation deformity associated with submuscular implant reconstruction since 2014. We wished to evaluate the indications for the surgery and the outcomes for patients undergoing revision of an implant reconstruction to the prepectoral plane with ADM (Acellular Dermal Matrix) coverage.

P46. COMPLICATIONS IN PREPECTORAL TISSUE EXPANDER PLACEMENT: A SINGLE INSTITUTION STUDY

PURPOSE: Prepectoral two-stage post-mastectomy breast reconstruction has increased in the recent time period. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced post-operative pain, but its complication profile is currently unclear. The aim of this study is to examine the complication profile of prepectoral tissue expanders (TEs) at our institution. METHODS: We performed a retrospective review of patients who underwent immediate reconstruction with a prepectoral TE from 2018-2020 at Memorial Sloan Kettering Cancer Center. Basic demographics and comorbidities were evaluated. Outcomes of interest included seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision (MSFN), TE exposure, capsular contracture, and TE loss. Multivariate logistic regression assessed factors associated with increased odds of TE loss. RESULTS: A total of 574 patients (952 TEs) were included. Overall, 78.6% of mastectomies were skin-sparing, 71.2% of TEs were smooth, 82.6% used acellular dermal matrix (ADM), and 46.6% used SPY angiography. Most frequent complications were seroma (9%), infection/cellulitis (8%), and TE loss (4.6%). Hematoma, TE exposure, and MSFN each had complication rates of 2%. Fewer than 1% of patients experienced capsular contracture. Diabetics (OR=1.09, p=0.02), former smokers (OR=2.45, p<0.01), and increasing mastectomy weight (OR=0.001, p=0.04) had increased odds of TE loss. TE loss was not associated with TE surface type, ADM use, or SPY use. CONCLUSION: Prepectoral reconstruction is a reasonable and safe alternative to subpectoral TE placement. Further research examining the quality of the soft tissue envelope and pocket size, as well as assessment of patient reported outcomes, would prove beneficial.

Submuscular Implant-Based Breast Reconstruction Using a Musculofascial Pocket Formed by the Pectoralis Major Muscle and the Serratus Anterior Muscle Fascia: A Novel Surgical Approach.

Subpectoral implant-based breast reconstruction following mastectomy commonly severs the inferior border of the pectoralis major muscle for better projection of the lower pole. This can affect a patient's postoperative motor function and result in animation deformity. Implant-based breast reconstruction using partial muscle coverage with an acellular dermal matrix (ADM) can be costly. There is an unmet clinical need for a novel surgical method for submuscular implant-based breast reconstruction. We describe an innovative technique for submuscular implant-based breast reconstruction following mastectomy. The approach utilizes the serratus anterior muscle fascia connected to the lateral margin of the pectoralis major muscle to form a lateral tissue pocket for implant coverage. This method preserves the inferior border of the pectoralis major muscle and minimizes the size of ADM coverage. Patient satisfaction on the BREAST-Q Reconstruction Module and complications were assessed 12months after surgery. The novel surgical design was safe and used minimal ADM (6 × 5cm2). Mean satisfaction with breasts was 61 ± 4.7 (range, 48-73), mean psychosocial well-being was 66 ± 10 (range, 50-93), and mean sexual well-being was 47 ± 7.8 (range, 27-70). Animation deformity was avoided by preserving the inferior border of the pectoralis major muscle. Rates of revision (7.6%) and postsurgical seroma (3.4%) were low, and capsular contracture was minimal. Submuscular implant-based breast reconstruction following mastectomy utilizing the serratus anterior muscle fascia connected to the lateral margin of the pectoralis major muscle to form a lateral tissue pocket for implant coverage is safe, feasible, and generates good aesthetic outcomes.

Extended Clinical Experience With Nipple-Sparing Mastectomy and Prepectoral Polyurethane Implant Positioning (BRAND4P method)

BackgroundDirect-to-implant prepectoral breast reconstruction in the last years demonstrated to be a feasible and advantageous method in selected cases because it respects chest wall musculature integrity and avoids animation deformity. Current approaches involve implant wrapping with Acellular Dermal Matrix (ADM) or synthetic mesh to guarantee implant coverage and stability and reduce complications. Prepectoral polyurethane implant positioning without further coverage is an alternative breast reconstruction method poor described in literature. Patient and MethodsA single-institution retrospective analysis was performed on 453 patients, extending our previous preliminary experience, who underwent nipple-sparing mastectomy (NSM) and prepectoral polyurethane implant positioning between December 2017 and June 2021. Follow-up included postoperative complications record and self-reported patient's satisfaction. ResultsA total of 784 mastectomies were performed in 453 patients. 331 were bilateral procedures (73.1%) and 122 were unilateral (26.9%). Minimum follow-up time was 6 months and maximum was 42 months. No major complications were reported. Contour defects and excessive implant visibility occurred in 82 patients (18.1%) and was successfully managed with autologous fat grafting. ConclusionNipple-sparing mastectomy with immediate prepectoral polyurethane implant reconstruction without the need for ADM or mesh is a feasible and safe option. Accurate patient selection and respectful mastectomy technique is crucial to achieve optimal outcomes with this approach. Fat grafting is a useful refinement procedure to improve cosmetic results in this setting.

Revising Prepectoral Breast Reconstruction.

Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis' unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author's (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.

Extramuscular and Intramuscular Course of the Nerve Innervating the Abdominal Part of the Pectoralis Major Muscle: An Anatomical Study with Regard to Transaxillary Endoscopic Subpectoral Breast Augmentation.

During transaxillary endoscopic subpectoral breast augmentation, the innervation of the abdominal part of the pectoralis major muscle can be injured. The question has been raised whether this could even be of value, as for a better result, the caudal fibers of the pectoralis major muscle have to be detached from their origin. The authors' aim was to identify the exact position and the intramuscular course and target of these nerve branches. Fifty pectoralis major muscles and their supplying nerve branches from 27 formalin-fixed anatomical specimens were studied using macroscopic dissection and anthropometry. Furthermore, eight muscles underwent the modified Sihler procedure to determine the intramuscular course and target of the supplying nerve branches. The branches for the abdominal part of the pectoralis major muscle pierced the pectoralis minor muscle or coursed around its lower border 3.2 to 8.4 cm from the tip of the coracoid process. Within the muscle, at least one small nerve branch, innervating the abdominal part, ascended into the lowermost portion of the sternocostal head, and anastomosed with the lowest small branch of its supplying nerve branches. Because of the variable position of the nerve branches, they may often cross the operative field during transaxillary endoscopic breast augmentation. However, their interruption can be of value, because weakening of the lower part of the pectoralis major muscle is desired to keep the implant in place, and to avoid animation deformity.

Prepectoral Conversion of Subpectoral Implants for Animation Deformity after Breast Reconstruction: Technique and Experience.

Background:Implant-based breast reconstruction in postmastectomy patients is commonly performed in a submuscular plane. Following reconstruction, animation deformity can be a displeasing aesthetic result for patients. In addition, patients may experience more postoperative pain with a submuscular reconstruction. Prepectoral conversion of submuscular implant position is an option for addressing these concerns. We describe a detailed technique and review our results.Methods:A retrospective review was conducted of all prepectoral conversions performed by the senior author (DSW) from 2017 to 2019 after IRB approval. All patients presented with animation deformity and another symptom such as asymmetry, pain, and/or capsular contracture. Patients underwent prepectoral conversion with smooth silicone gel implants. Demographic data, outcomes, and patient satisfaction were reviewed.Results:Prepectoral conversion was performed in 33 consecutive patients (57 breasts) with animation deformity. Twelve patients had capsular contracture, seven complained of pain, and five had ruptured implants. Postoperative complications included three infections requiring implant removal in two breasts, one implant exposure and one hematoma requiring implant replacement, five seromas requiring aspiration, and one capsular contracture. Seven patients had contour abnormalities addressed with secondary autologous fat grafting. Ultimately, all patients had elimination of animation deformity and were satisfied with the results of the conversion.Conclusions:Unsatisfactory results of subpectoral implant reconstruction such as animation deformity and chronic pain have led the reconstructive surgeon to consider various techniques to address these issues. The conversion to a prepectoral plane will effectively eliminate animation deformity, resolve pain, and yield satisfactory results in these patients.

One-Stage Mastopexy-Lipofilling after Implant Removal in Cosmetic Breast Surgery.

Revising unsatisfactory outcomes in breast augmentation represents one of the most challenging procedures in aesthetic breast surgery. Different techniques for revising unsatisfactory outcomes in breast augmentation have been described, which can be summarized in two options: implant replacement procedures and implant explantation procedures. Implant explantation procedures can be performed alone or in combination with other techniques to restore volume. Depending on the native volume, the shape and the elasticity of the remaining breast tissue, implant removal can be also associated with mastopexy, auto-augmentation mammoplasty or fat graft. This article portrays our series of combined mastopexy and lipofilling after implant explantation for revising unsatisfactory outcomes of breast augmentation. A prospective observational study was performed including all patients underwent cosmetic one-stage mastopexy-lipofilling after implant removal. Collected data included patient's age and BMI, smoking, previous scar location (periareolar, inframammary fold or trans-axillary), implant characteristics (size and location), reason why patient wants to remove the implant (capsular contracture, implant rupture, animation deformity, chronic pain, asymmetry), mean liposuction and fat injection volume, type of capsulectomy, mean operating time and postoperative complications. Cosmetic results and patient satisfaction were evaluated using the 5 points Likert scale and BreastQ reduction/mastopexy module, respectively. A total of 14 patients (28 breasts) were included with a mean follow-up of 11.3 months. Mean liposuction and injection volumes were 980 mL and 295 mL, respectively. Regarding breast volume, a reduction in one-cup size was noted in 100% of cases. Only one patient (7.69%) requested additional breast volume and underwent a second fat grafting session. Regarding aesthetic outcomes, the mean scores for breast volume, shape, symmetry, quality of scars, nipple-areola complex and donor site shape were 4.2, 4.2, 4.9, 4, 4.3 and 4.7, respectively. BreastQ showed an improvement of patients reported satisfaction with a median (Quartile Rank) score increase of 19 points for the "satisfaction with breast" domain (p &lt; .00001) and a decrease of 17 points for the "physical well-being" domain (p &lt; .00001). "Satisfaction with outcomes" median (Quartile Rank) score was 72. Combined mastopexy and lipofilling after implant removal represents a new tool in plastic surgeon armamentarium. This technique is indicated in patients who do not desire anymore breast implant, presenting ptosis of the remaining breast gland and donor site availability. Our article suggested that combined mastopexy and lipofilling achieves satisfactory aesthetic results and excellent patient-reported outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Correction of Breast Animation Deformity with Implant Pocket Conversion to a Prepectoral Plane.

We have read with interest the article by Holland et al.1 on prepectoral conversion as a treatment for animation deformity in patients with retropectoral breast implants. Animation deformity is a breast distortion caused during contraction of the pectoralis major in women with retropectoral implants, which can happen both in breast augmentation surgery and in reconstruction after mastectomy. The incidence of animation deformity varies according to the surgical technique used, reaching 75 percent to 100 percent in reconstructions after mastectomy.2–4 Various methods have been described for treating animation deformity, including selective nerve sectioning, replacing the implants by a muscle flap, conversion according to the split-muscle technique, and that described in the article by Holland et al.1 for prepectoral conversion. This last method is booming, given that it resolves the animation deformity in 100 percent of the cases.5 However, we believe that prepectoral conversion presents some limitations. First, this surgery theoretically restores the function of the pectoralis major by fixing its distal fibers to the chest wall. Nevertheless, the function of this muscle has already been supplied by other muscle groups; therefore, patients typically have no functional limitations. Second, this surgery is not without complications. In fact, Holland et al.1 reported an infection rate of 13.8 percent and a 6.3 percent rate of capsular contracture. Third, the cosmetic results can be suboptimal due to visibility of the implant, requiring revision surgery in 11.3 percent of patients.1 For this reason, Holland et al.1 in their series contraindicate the procedure for those women with a pinch test less than 1 cm who do not have donor fat. They used a biological mesh to cover the implant in 81 percent of patients, and in 52.5 percent, they performed lipofilling before the prepectoral conversion, thereby increasing the costs of the process. We recently treated a 26-year-old patient with retropectoral breast augmentation implants who presented with bilateral animation deformity and had undergone surgery on five occasions in various centers to correct this deformity without success. In our unit, we proposed sectioning the pectoralis major using a transcapsular approach. The surgery consisted of an incision in the inframammary fold, sectioning of the periprosthetic capsule, and withdrawal of the implant. Subsequently, we identified the muscle fibers responsible for the animation deformity using an electrical muscle stimulator (6 Hz; 400 μsec; 35 mA; 1 second of pause and 4 seconds of activity). Once we had performed the sectioning of the muscle fibers, we activated the electrical muscle stimulator to confirm elimination of the animation deformity. Many reasons motivate us to propose this procedure as an alternative for women with retropectoral implants and recurrent animation deformity. First, the technique has lower morbidity compared with prepectoral conversion due to not requiring capsulectomy and a new pocket for the implant. Second, the technique can be performed in patients with scarce subcutaneous tissue. Lastly, the procedure preserves the muscle coverage that provides an optimal cosmetic result because it reduces the implant’s visibility without needing a mesh or lipofilling, which increase the costs and complications of the surgical process. The technique of sectioning the pectoralis major guided by an electrical muscle stimulator should therefore be considered an alternative for resolving animation deformity. Its main advantages are its low morbidity, low cost, and good cosmetic results. However, prospective studies will be needed to assess the results of this technique. DISCLOSURE The authors have no disclosure or financial support to report. Benigno Acea-Nebril, M.D., Ph.D.Alejandra García-Novoa, M.D., Ph.D.Isabel Casal-Beloy, M.D., Ph.D.Breast UnitSurgery DepartmentHospital QuirosanludA Coruña, Spain

Direct-to-Implant Prepectoral Breast Reconstruction: Patient-Reported Outcomes.

Direct-to-implant prepectoral breast reconstruction has recently experienced a resurgence in popularity because of its lower levels of postoperative pain and animation deformity. BREAST-Q, a well-validated patient-reported outcomes tool, was used to assess patient satisfaction and quality of life. The goal of this study was to assess patient-reported outcomes at 6-month and 1-year follow-up after direct-to-implant prepectoral breast reconstruction. Sixty-nine consented adult patients undergoing a total of 110 direct-to-implant, prepectoral, postmastectomy breast reconstructions completed BREAST-Q questionnaires immediately preoperatively, and at 6 and 12 months thereafter. Mean breast satisfaction decreased nonsignificantly from 61.3 preoperatively to 58.6 at 12 months after reconstruction (p = 0.32). Psychosocial well-being improved nonsignificantly from 67.1 preoperatively to 71.1 at 12-month follow-up (p = 0.26). Physical well-being of the chest was insignificantly different, from 74.4 to 73.3 at 12-month follow-up (p = 0.62). Finally, sexual well-being similarly remained nonsignificantly changed from 60.2 preoperatively, to 59.1 at 12 months (p = 0.80). The use of acellular dermal matrix and postmastectomy radiotherapy did not have any significant effects on patient-reported outcomes. Through regression analysis, neoadjuvant chemotherapy, increased age, and incidence of rippling were found to negatively influence BREAST-Q results. Patients who underwent direct-to-implant prepectoral breast reconstruction demonstrated an overall satisfaction with their outcomes. As prepectoral breast reconstruction continues to advance and grow in popularity, patient-reported outcomes such as those presented in this study become of paramount importance in practice. Therapeutic, IV.

Comparing post-surgical outcomes of pre-pectoral versus dual-plane direct-to-implant breast reconstruction without increasing the use of acellular dermal matrix

Direct-to-implant (DTI) reconstruction when performed using the dual-plane technique can be associated with increased postoperative pain, longer recovery, functional impairment, and animation deformity. These issues can be avoided by using the pre-pectoral technique that traditionally uses larger pieces of the acellular dermal matrix (ADM) and results in increased costs. It is unclear how these two methods compare when the technique is modified to avoid the use of additional ADM. A retrospective chart review was conducted of all patients who underwent DTI breast reconstruction using a dual-plane or pre-pectoral technique between January 2014 and December 2019. Pre-pectoral breast reconstruction was performed using a partial anterior coverage technique, and therefore no additional ADM was used per case as compared to the dual-plane technique. Rates of post-surgical complications were compared between the two groups. Of 77 patients, 48 (86 breasts) underwent dual-plane reconstruction, whereas 29 (48 breasts) underwent pre-pectoral reconstruction. Mean follow-up time for the dual-plane and pre-pectoral groups was 23.3 and 8.7 months, respectively (p<0.001). There were no significant differences in the rates of any of the short-term post-surgical outcomes between the two groups: seroma (14% vs 6.3%, p=0.175); hematoma (2.3% vs 4.2%, p=0.617); skin/nipple necrosis (7% vs 10.4%, p=0.522); wound skin infection (2.3% vs 2.1%, p=1.0); wound dehiscence (4.7% vs 2.1, p=0.654); and implant loss (1.2% vs 8.3%, p=0.055). Pre-pectoral reconstruction using a partial anterior coverage technique appears to be a safe alternative to dual-plane reconstruction when considering short-term post-surgical complications.

Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update.

Background:Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction.Methods:This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included.Results:Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction.Conclusions:Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction.

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of prepectoral breast reconstruction. 2. Have knowledge of primary immediate and delayed prepectoral breast reconstruction techniques and secondary procedures required. 3. Describe data on outcomes of prepectoral breast reconstruction. Once considered to have an unacceptable complication profile, prepectoral breast reconstruction is increasing in popularity because of decreased surgical invasiveness and postoperative pain and the absence of animation deformity. Short-term outcomes studies comparing prepectoral breast reconstruction to partially submuscular techniques demonstrate similarly acceptable rates of postoperative complications. Aesthetic outcomes demonstrate similar rates of capsular contracture but increased rippling and implant palpability of the upper pole. Postoperative functional data are limited but overall show decreased pain and more rapid return of function but equivalent satisfaction on the BREAST-Q. Long-term aesthetic data and rates of revision are lacking.

A Critical Appraisal of Late Complications of Prepectoral versus Subpectoral Breast Reconstruction Following Nipple-Sparing Mastectomy.

Nipple-sparing mastectomy (NSM) offers improved aesthetics without compromising oncologic safety. Subpectoral breast reconstruction has long been standard practice, although prepectoral reconstruction has recently resurged in popularity. Due to this recent paradigm shift, studies comparing long-term outcomes by reconstructive plane are lacking. A retrospective review was conducted on consecutive NSMs with implant-based reconstruction in either the prepectoral or subpectoral plane from 2014 to 2018. Patient demographics, implant specifications, and operative details were collected to evaluate primary outcomes of prosthetic failure and unplanned reoperations by reconstructive plane. Secondary outcomes included animation deformity, capsular contracture, rippling, plane change, and minor revisions, including fat grafting. Bivariate and multivariate analyses were performed to assess outcomes. Overall, 405 NSMs were performed on 228 women (subpectoral=202, prepectoral=203), with a mean follow-up of 2.1years (standard deviation 1.1). During the study period (2014-2018), a shift from subpectoral to predominantly prepectoral mastectomies occurred in 2017. Prepectoral reconstructions were more often direct-to-implant (DTI) compared with subpectoral (73.9% vs. 33.2%, p<0.001). Prepectoral reconstruction demonstrated significantly reduced prosthetic failure (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.14-0.65) and unplanned reoperations (OR 0.43, 95% CI 0.24-0.77) compared with subpectoral reconstruction after controlling for implant characteristics and other possible confounders. Prepectoral patients experienced decreased animation deformity overall (19.7% vs. 0.0%, p<0.001), with plane changes seen in 10.6% of subpectoral reconstructions for animation deformity correction. Prepectoral patients experienced an increase in rippling (15.3% vs. 6.1%, p=0.003) without a significant increase in fat grafting (subpectoral=11.6% vs. prepectoral=12.3%, p=0.829). This single-institution experience compares late complications of prepectoral and subpectoral implant-based reconstruction following NSM. Prepectoral reconstruction can be safely performed with improved understanding of mastectomy planes, readily affords DTI reconstruction, and reduces animation deformity at the expense of rippling.

Short- to Medium-term Outcome of Prepectoral versus Subpectoral Direct-to-implant Reconstruction using Acellular Dermal Matrix.

Background:Subpectoral implant reconstruction (SIR) is associated with animation deformity and increased postoperative pain. The aim of our study was to compare the short- to medium-term outcome of prepectoral implant reconstruction (PIR) and SIR with acellular dermal matrix.Methods:A review of prospectively collected data of patients who underwent PIR and SIR using biological mesh by a single surgeon between Nov 2016 and Nov 2020 was done. Presentation, smoking history, BMI, bra size, radiology size, pathology data, mastectomy weight, implant volume, radiation treatment, and outcomes were analyzed. For intergroup comparisons, the data were analyzed using Pearson chi-square test and the Student t-test. P values of less than 0.05 were considered statistically significant.Results:Eighty-two patients had 109 implant reconstructions (85 PIR and 24 SIR). Median follow-up was 27 months (4–53). Twenty-five of PIR and six of SIR were risk reduction surgeries. Two groups were comparable except for significantly higher percentage of node positive (13/18, 72% versus 20/60, 33%; P = 0.003), Her 2-positive disease (7/18, 39% versus 9/60, 15%; P = 0.027), and radiotherapy (15/24, 63% versus 21/85, 25%; P = 0.001) in SIR. There was no statistically significant difference between the two groups with regard to hematoma, wound infection, red reaction, seroma needing aspiration, wound necrosis, and implant loss. Significantly more patients in the prepectoral group had rippling needing fat grafting (n = 13, 15% versus 0; P = 0.041) and significantly more patients in the subpectoral group had fat grafting for contour deformity (n = 6, 25% versus n = 6, 7%; P = 0.025).Conclusion:PIR is comparable to conventional SIR with regard to most of the complications.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction.

Background:Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.Methods:To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.Results:Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).Conclusions:Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Extension toward the Trapezius in a Transversely Oriented Latissimus Dorsi Flap for Breast Reconstruction.

Background:A transverse paddle latissimus dorsi (LD) flap has the advantage that if the skin paddle is placed in the transverse bra line, the donor site scar is well hidden by underwear. With this transfer, medial back tissues are usually moved to the medial area of the reconstructed breast following 180 degree rotation. Because these tissues are thinner than the lateral thoracic area, the medial part of the reconstructed breast sometimes becomes flatter than expected.Methods:To add bulk in the medial lower quadrant for giving an impression of an outward-expanding breast, we modified the LD flap by adding a part of the trapezius muscle. Seven patients underwent mastectomy and simultaneously received a modified LD flap. To hide the donor site scar beneath underwear, the skin paddle needed to be oriented transversely. The additional harvested tissues were tested for vascularity by fluorescence following intravascular injections of indocyanine green. If this was negative, the tissue was not used for breast reconstruction. Postoperatively, another surgeon judged whether this modification had contributed favorably to the reconstructed medial lower quadrant.Results:Indocyanine green testing was positive in six cases. The shape of the lower medial quadrant was judged as good in five of the seven cases. Complications included an animation deformity of the LD muscle, donor site seroma, and donor site wound dehiscence.Conclusion:This transversely oriented LD flap with extension to the trapezius muscle placed at the bra-line is one option to add bulk to the medial lower quadrant of the reconstructed breast when an additional scar is not desired for cosmetic reasons.