Visualized pre- and subpectoral implant placement for immediate breast reconstruction

Introduction

A paradigm shift in modern breast reconstruction occurred in 2001 with the introduction of acellular dermal matrix (ADM) allowing a direct to implant breast reconstruction that has become a standard procedure and evolved further using various types of biological and synthetic meshes (1-4). The increased practice of one stage direct to implant reconstruction has resulted in an increased focus on the unsightly breast animation deformity (BAD) that has been suggested to be proportional to the degree of muscle involvement (5).

Prepectoral placement of the implant has resurrected as an alternative to avoid the BAD results. This change however, gives a resurgence of potential problems such as thin tissue coverage allowing visible implant edges, secondary ptosis and possibly increased rates of capsular contracture. These are potential risks, which needs to be examined in future studies (5,6). The aim of this visualized surgery paper was to visualize and highlight the technical disparities between a sub- and prepectoral direct to implant breast reconstructive techniques applied at our institutions.

Operative techniques

Video 1 (Figure 3)

Figure 3 Subpectoral implant placement for immediate breast reconstruction, video 1 (7). Available online: http://www.asvide.com/watch/32973

This video demonstrates a subpectoral direct-to-implant breast reconstruction directly applied after mastectomy of the patients right breast (Figures 1-3).

Figure 1 Patient with a tumor in the right breast below the nipple. Before surgery.

Figure 2 The same patients after surgery. The nipple had to be removed in a secondary procedure due to close margins.

The breast base and the inframammary crease were marked, and the width, height and projection of the breasts were measured. Prior to surgery the breast parenchyma, tumor and flap thickness as well as junction between the subcutaneous fat and the breast parenchyma were assessed by a T2-weighted MR scan. The MRI is not necessary for this procedure, however we find that the procedure is more secure in our hands when using MRI as skin flap thickness can be estimated and the tumor localization is more precise.

Following nipple sparing mastectomy, the mastectomy flap viability and thickness was evaluated by vision and palpation prior to reconstruction. The subcutaneous pocket was thoroughly washed with saline. Monopolar cautery was used to dissect a pocket under the pectoralis major muscle, which insertion was released inferomedially. The choice of implant was based on measurements and the use of an inflatable sizer. We used a porcine derived mesodermal matrix, Meso Biomatrix^®, for inferior support of the implant. The matrix was sutured by running Vicryl 2.0 sutures to the edge of the pectoralis major muscle and the thoracic wall along the location of the inframammary crease.

The implant was placed in the pocket and the matrix was then sutured laterally to complete the muscle/matrix pocket. We do not rinse the implant pocket in antibiotics as a standard.

Two drains were placed and the skin edges at the IMF were deepithelialized prior to suturing by 3.0 running vicryl and 3.0 running monocryl sutures. We use a transparent drape for 14 days to support the reconstruction and allow for skinflap and wound observation without dressing removal.

Video 2 (Figure 4)

Figure 4 Prepectoral implant placement for immediate breast reconstruction, video 2 (8). Available online: http://www.asvide.com/watch/32974

This video demonstrates a prepectoral direct-to-implant breast reconstruction on the left breast in a risk reducing case (Figure 4).

Following nipple sparing mastectomy, the mastectomy flap viability and thickness was assessed by vision and palpation prior to reconstruction. The subcutaneous pocket was thoroughly washed out with 0.9% saline. Two pieces of porcine derived mesodermal matrix, Meso Biomatrix^®, were sutured to the pectoralis major muscle and the thoracic wall using a running Vicryl 2-0 sutures circumferentially along the breast footprint, where the implant was to be placed. The chosen implant was inserted between the two pieces of mesh creating a prepectoral implant pocket. The mesh edges were then sutured together above the implant by running vicryl 2.0 sutures thereby closing the pocket. Two drains were placed, and the skin sutured as described above.

Comments

In this paper we visualize our two preferred techniques for direct to implant breast reconstruction, subpectoral and prepectoral, using a mesodermal matrix as a hammock. Currently, we are conducting a randomized study to examine if one of these techniques should be preferred to the other. We started using subpectoral ADM assisted direct to implant breast reconstruction in 2011 (3,9-12). However, when tested at follow-up nearly all of our patients had BAD to some extent. Since 2015 we have changed the implant pocket from subpectoral to prepectoral in the patient with a severe degree of BAD. However, this is not possible in all cases due to thin tissue coverage.

The prepectoral pocket change clearly seems to reduce the incidence of BAD. Currently, we apply both techniques, as visualized in the two videos. The prepectoral placement is somewhat faster to perform and on the short-term seems to be associated with a less pain and reduced drain output compared to the subpectoral technique (13).

However, our experience is still relatively short and user dependent so knowledge about the patients perception of the cosmetic and functional outcomes of the two techniques needs to be assessed and compared. Furthermore, we need long-term data about rippling, visible implant edges, ptosis and capsular contracture and other morbidities that implants are known to cause in cosmetic and reconstructive breast surgery.

We are currently comparing the two techniques with regard to BAD, cosmetic and functional outcome as well as patient related outcome to gain more knowledge about the advantages and disadvantages of the two techniques. Patient selection is important, and we based the selection on clinical evaluation and supplemented by a preoperative T2 weighed MRI scan, which in our experience give valuable information about the thickness of the subcutaneous tissue layer, the Coopers ligaments as well as the location and size of tumours in cancer patients.

Reports of prepectoral implant based reconstructions have increased at a rapid pace over the last years (14,15). The publications are mostly studies reporting that the prepectoral technique is feasible and safe to perform, but tells us little to none about patient related outcomes on short- or long-term (16). Currently there is a clear trend and shift toward prepectoral implant placement to reduce the degree of BAD, although little is known about the other outcome measures, such as capsular contracture, bottoming out, implant visibility, rippling and most importantly patient related outcome measures as reported by for instance Breast-Q (5,17).

Prepectoral and subpectoral implant based immediate breast reconstruction needs to be compared in prospective trials recording the morbidity and patient related outcomes associated to these procedures. In this visualized surgery paper, we visualize the technical disparities between the sub- and prepectoral direct to implant breast reconstructive techniques, which we are currently comparing in a prospective randomized trial.

Acknowledgments

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

References

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