Submuscular Breast Reconstruction Research Articles

Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy.

Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results. The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients. We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest. We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved. The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy.

Reducing Peri-implant Capsule Thickness in Submuscular Rodent Model of Breast Reconstruction With Delayed Radiotherapy

IntroductionCapsular contracture remains the most common complication following device-based breast reconstruction, occurring in up to 50% of women who also undergo adjuvant radiotherapy either before or after device-based reconstruction. While certain risk factors for capsular contracture have been identified, there remains no clinically effective method of prevention. The purpose of the present study is to determine the effect of coating the implant with the novel small molecule Met-Z2-Y12, with and without delayed, targeted radiotherapy, on capsule thickness and morphologic change around smooth silicone implants placed under the latissimus dorsi in a rodent model. MethodsTwenty-four female Sprague Dawley rats each had 2 mL smooth round silicone breast implants implanted bilaterally under the latissimus dorsi muscle. Twelve received uncoated implants and twelve received implants coated with Met-Z2-Y12. Half of the animals from each group received targeted radiotherapy (20 Gray) on postoperative day ten. At three and 6 months after implantation, the tissue surrounding the implants was harvested for analysis of capsular histology including capsule thickness. Additionally, microCT scans were qualitatively analyzed for morphologic change. ResultsCapsules surrounding Met-Z2-Y12-coated implants were significantly thinner (P = 0.006). The greatest difference in capsule thickness was seen in the irradiated 6-month groups, where mean capsule thickness was 79.1 ± 27.3 μm for uncoated versus 50.9 ± 9.6 μm for Met-Z2-Y12-coated implants (P = 0.038). At the time of explant, there were no capsular morphologic differences between the groups either grossly or per microCT. ConclusionsMet-Z2-Y12 coating of smooth silicone breast implants significantly reduces capsule thickness in a rodent model of submuscular breast reconstruction with delayed radiotherapy.

A Two-Year Retrospective Analysis of the Clinical Outcomes of Immediate Submuscular Breast Reconstructions With Native® Acellular Dermal Matrix.

Implant-based submuscular breast reconstruction (SBR) can be performed with the aid of acellular dermal matrices (ADM) for implant coverage on their inferolateral pole, aiming at providing a biological interface for hiding the implant and therefore reducing the risk of complications. The purpose of this study is to assess the long-term post-operative outcomes obtained using the SBR-specific Native® ADM (DECO med s.r.l., Marcon, Venice, Italy). All cases of Native®-assisted immediate SBR performed at our institution between October 2016 and March 2020 were retrospectively analysed. Demographic and surgical data were collected, and post-operative outcomes, including minor and major complications, were evaluated. Particular attention was paid to complications emerging before and after patient discharge. Dependence analyses were performed to uncover statistically significant relationships between risk factors and reconstructive outcomes. Data on 100 patients were collected, for a total of 128 breasts. The mean age of the cohort was 49.5 years, the mean BMI was 23.4 kg/m2, and the mean follow-up was 24 months. Out of this, 14.1% of patients received pre-operative radiotherapy, while 16.4% underwent post-mastectomy radiotherapy. Breasts appeared to develop short-term minor complications more likely during hospitalisation (11.7% vs. 7.8%), while short-term major complications occurred more often after discharge (7.8% vs. 15.6%). The most frequent long-term complications were capsular contracture and contour defects (both 9.4%). Risk factors that showed a statistically significant relationship with complications were pre- and post-mastectomy radiotherapy and post-operative chemotherapy. The retrospective analysis showed results in line with clinical outcomes reported in the literature for the same reconstructive technique. The use of Native® ADM in SBR is safe and effective in the long term.

Mastectomy and immediate prepectoral versus submuscular breast reconstruction after neoadjuvant chemotherapy: Our early experience.

e12618 Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that allows to improve aesthetic results and patient quality of life. Traditionally, implants have been placed in a submuscolar (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of prosthesis is increasingly used in order to avoid morbidities related to manipulation of PMM. The aim of this study was to compare outcomes of SM vs PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our Istitution from January 2018 to December 2021. Conservative mastectomy was performed in 155 of the 400 patients that underwent NAC during the study period. Patients were divided in 2 groups based on the positioning of implants: 60 SM versus 95 PP. Results: The two cohorts were similar for age (mean age 45 and 42 years in the SM and PP group respectively) and follow‐up (32 and 21 months, respectively). Mean operative time was 55 minutes shorter in the PP group (298 and 243 minutes in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss occurred was observed in 1.6% of patients (1/60) in the SM group and 1,05% of patients (1/95) in PP group. No differences were observed among the two groups in local or regional recurrence. Conclusions: Our preliminary experience, that represents one of the largest series of PP-IPBR after NAC at a single Institution documented in the Literature, seems to confirm that PP - IPBR after NAC is a safe, reliable and effective alternative to traditional SM - IPBR with excellent aesthetic and oncological outcomes; it is easy to perfom, reduces operative time and minimizes complications related to manipolation of PPM. However this promising results need to be confirmed in prospective trials with longer follow-up.

The Technique of Scarless Latissimus Dorsi in Immediate Breast Reconstruction.

Background: In dealing with the inferior pole coverage of an implant or a tissue expander in the partial submuscular technique, various surgical strategies have been introduced over the years. Among them, ADM and synthetic meshes were intensively studied and performed in order to obtain a good aesthetic result with satisfactory lower pole contouring, create a strong support of the implant and offer flexibility in adapting the volume of a tissue expander to the remaining mastectomy flaps (1,2). However, the viability of the skin from the mastectomy flaps is not always optimal. Vascular impairment and subsequent necrosis can occur at various extent in the mastectomy flaps (3). The necrosis of the mastectomy flaps is unpredictable and sometimes occurs with no obvious cause (4). Implant exposure and extrusion, ADM or mesh exposure are serious complications which can lead to the reconstructive failure. Methods: The scarless latissimus dorsi flap technique was introduced and observed in patients eligible for skin sparing and nipple sparing mastectomy with implant-based submuscular breast reconstruction. The keypoints of the surgical steps are described. Results: The main priorities of the outcome of the reconstructive process were stability and good definition of the lower pole of the reconstructed breast. The good vascularized underlying muscular tissue totally covering the implant increases chances in avoiding exposure or extrusion of the implant. In the advent of partial mastectomy flap necrosis, the healing by secondary intention provided good and stable results. Also, this technique decreases the morbidity and risks related with the change of the patient position during the procedure, improves the aesthetic results, by avoiding additional incisions for harvesting the flap. Conclusions: The scarless latissimus dorsi flap in implant based breast reconstruction is a valuable option for stable results and viable alternative to the use of ADM.

Sub-muscular Reconstruction after NAC Sparing Mastectomy: Direct to Implant Breast Reconstruction with Human ADM Versus Tissue Expander.

Nipple areola complex (NAC) sparing mastectomy allows good oncological and aesthetic results. The study compares the results, in terms of self-evaluated satisfaction and symmetry, of direct to implant (DTI) sub-muscular breast reconstruction, with the aid of human acellular dermal matrix (ADM) versus two-stage reconstruction with sub-muscular tissue expander, followed by implant. This is a retrospective, observational, single-center, non-randomized, case-control study. Inclusion criteria were: unilateral NAC sparing mastectomy at Forlì Hospital between 2014 and 2018; sub-muscular reconstruction; minimum follow-up of 12months from the reconstructive stage; no history of radiotherapy. Patients were divided into two groups: group A included patients who underwent DTI breast reconstruction with the aid of human ADM; group B were those who underwent a two-stage reconstruction with tissue expander then implant. We collected data on: (1) Self-evaluated satisfaction by Breast Q questionnaire (scores from 0 to 100). (2) Observer-evaluated symmetry. Bi-dimensional photographs were collected and evaluated by 11 breast surgeons blinded to each other, who assigned a score for symmetry (from 0 to 10). (3) Symmetry of anthropometric measures collected by hand and volume estimated by Breast V application. Group A included 28 patients; group included B 26 patients. Breast-Q questionnaires reported the following results: satisfaction with breasts in group A 65 ± 12 versus group B 68 ± 14; satisfaction with outcome in group A 88 ± 16 versus group B 93 ± 11; psychosocial well-being in group A 71 ± 20 versus group B 76 ± 17; sexual well-being in group A 63 ± 26 versus group B 60 ± 13; physical well-being in group A 68 ± 15 versus group B 60 ± 12. The average symmetry breast score assigned to group A was 6.9, versus group B 7.2. Regarding the anthropometric measures in group A, the differences between right and left were major to those in group B. Regarding breast volume, the mean difference between right and left in group A was 31.89cc ± 24.97, whereas in group B was 25.46cc ± 23.59. Our data show better symmetry and better psychosocial well-being in the two-stage reconstruction, and higher satisfaction with sexual and physical well-being in DTI reconstructions. These aspects should be discussed with the patient while collecting the informed consent. 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 .

Correction of animation deformity with subpectoral to prepectoral implant exchange

Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

Cortiva Versus AlloDerm Ready-to-use in Prepectoral and Submuscular Breast Reconstruction: Prospective Randomized Clinical Trial Study Design and Early Findings.

Background:Several acellular dermal matrices (ADMs) can be used to provide soft-tissue support for post- and prepectoral prosthetic breast reconstructions. Yet, several recent meta-analysis suggest that due to a lack of rigorous evaluation in the setting of head-to-head prospective randomized control trials, few reliable conclusions regarding performance outcomes can be drawn. We compare Cortiva 1 mm to AlloDerm RTU in the setting of submuscular reconstruction in one study, and prepectoral in the second. Moreover, we present the findings from the interim analysis in our submuscular study.Methods:Using a single-blinded prospective randomized control trial design, we compare outcomes in 180 patients undergoing submuscular breast reconstruction with 16 × 8 cm ADM support (either Cortiva 1 mm or AlloDerm RTU). A parallel study evaluates 16 × 20 cm sheets of these ADMs in 180 patients undergoing prepectoral reconstructions. Time to drain removal, complications, fill volumes, patient-reported outcomes, and narcotic consumption are prospectively evaluated.Results:Interim analysis of 59 breasts in the submuscular study arm (Cortiva n = 31; AlloDerm n = 28) revealed no statistically significant differences with respect to outcome. At the time of interim analysis, the AlloDerm RTU group contained a higher proportion of never-smokers (P = 0.009), while patients implanted with Cortiva 1 mm received a larger tissue expander (P = 0.02).Conclusion:We present a protocol for a robust randomized control trial to evaluate outcomes in both submuscular and prepectoral prosthetic breast reconstruction assisted by 2 distinct types of ADM. Our interim analysis reveals no evidence of inferiority of outcomes in a comparison of AlloDerm to Cortiva.

Human acellular dermis increases surgical site infection and overall complication profile when compared with submuscular breast reconstruction: An updated meta-analysis incorporating new products✰

BackgroundHuman acellular dermal matrix (HADM) is an increasingly used adjunct to breast reconstruction. Previous meta-analyses demonstrate increased risks of complications, but these studies largely represent one product. The purpose of this study is to stratify outcomes on the basis of a meta-analysis of complications incorporating all new studies after 2012 and their associated new human-based products. MethodsA query of the MEDLINE database for articles on HADM and breast reconstruction from January 2012 to October 2015 yielded 172 citations. Two levels of screening identified 47 relevant studies. Thirteen studies were used in comparative meta-analysis. ResultsComplication rates were higher in HADM patients: total complications, 17.7% versus 6.1%; seroma, 8.3% versus 5.4%; infection, 7.2% versus 5.9%; and flap necrosis, 14.7% versus 7.1%. Meta-analysis revealed a statistically significant increased risk of total complications in patients who underwent reconstruction with HADM when compared with their submuscular reconstruction cohort (p = 0.03; relative risk (RR) = 1.46; confidence interval (CI): 1.04–2.04). Patients who underwent reconstruction with HADM demonstrated a significantly increased risk of flap necrosis (p < 0.01; RR = 2.39; CI: 1.8–3.16) and infection (p = 0.02; RR = 1.5; CI: 1.07–2.09) when compared with those who underwent submuscular reconstruction. There was no significant difference in seroma, hematoma, or implant explantation between these two groups. ConclusionsThis study suggests an increased risk of overall complications, specifically infection and flap necrosis, in patients who underwent tissue expander/implant breast reconstruction with HADM when compared with those who underwent submuscular placement. This must be weighed against the advantages in enhancing aesthetic outcomes, increasing intraoperative fill volume, and ameliorating capsular contracture.

Human Acellular Dermis versus Submuscular Tissue Expander Breast Reconstruction: A Multivariate Analysis of Short-Term Complications

BackgroundAcellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) registry.MethodsPatients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups.ResultsA total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01).ConclusionsThe NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

Submuscular breast reconstruction—Indications and techniques

Submuscular breast reconstruction—Indications and techniques

Submuscular Breast Reconstruction— Indications and Techniques

We review the care and treatment of 93 patients who underwent submuscular breast reconstruction in our service between 1975 and 1980. The indications and clinical situations in which submuscular reconstruction has been useful include: following simple mastectomy; following modified radical mastectomy; following subcutaneous mastectomy (immediate or delayed reconstruction); in standard augmentation mammaplasty in selected patients; and with unusual, unsatisfactory, or dangerous preexisting breast conditions. Unusual indications include unsatisfactory subcutaneous placement with capsule formation after subcutaneous mastectomy; use of unsatisfactory or dangerous implants such as Ivalon and Etheron; and replacement of the old-fashioned Cronin gel implants with fixation patches. Submuscular placement has also been used to advantage in patients with excessively scarred, tenuous skin. Technical modifications in the submuscular implantation technique are detailed. We have used subserratus-subpectoral placement in most instances. Technical tips to keep the implant in a low position by division of the serratus attachments and limitations of upward dissection are detailed. Clinical studies on the upward migration of implants and pressures developed under the serratus and pectoralis muscles as measured by manometer are also detailed.