Comparison of Sub-Pectoral and Pre-Pectoral Direct-to-Implant Breast Reconstruction Techniques

Background: Staged sub-pectoral expander-implant has been the gold standard for breast reconstruction since the 1980s. The sub-pectoral plane is utilized to provide a robust barrier between the implant and overlying skin, and capsular contracture reduction.¹ Tissue expansion ensures adequate mastectomy skin flap size and overlying tissue perfusion after implant placement.² Advances in breast reconstruction have been possible with the advent of acellular dermal matrices, autologous fat grafting, cohesive prosthetic devices, and intraoperative angiography.³ We have previously demonstrated that single-stage direct-to-implant pre-pectoral reconstruction is a safe and effective option for breast reconstruction.⁴ This option avoids pectoralis major morbidity and post-operative animation deformity. In this study, we aim to explore the pre-pectoral plane as a viable alternative to the sub-pectoral plane. We compare post-operative outcomes of single-stage direct-to-implant sub-pectoral and pre-pectoral breast reconstruction techniques.

 

Methods: Authors performed a retrospective review of pre-pectoral and sub-pectoral breast reconstructions performed by a single surgeon. Implants placed in the pre-pectoral plane were supported with total anterior AlloDerm coverage. Sub-pectoral implants had inferior pole coverage with an Alloderm sling. Indocyanine green fluorescence was used for evaluation of mastectomy skin flap perfusion.

 

Results: 140 women underwent 194 pre-pectoral breast reconstructions and 119 patients underwent 170 sub-pectoral breast reconstructions. Average follow-up periods for the study groups were 1.53 and 3.67 years, respectively. Analysis of patient data demonstrated sub-pectoral breast reconstruction patients had more post-operative radiation, longer follow-up (as they preceded the pre-pectoral technique), and more skin sparing (versus nipple sparing) mastectomy procedures.

Pre-pectoral breast reconstruction patients had higher incidences of minor seromas (managed with needle aspiration only) and no animation deformity.  Sub-pectoral patients had more full-thickness necrosis, capsular contraction and animation deformity. Explantation rates were similar between the 2 groups.

 

Conclusions: This study demonstrates that the pre-pectoral plane is a robust alternative to the sub-pectoral plane for immediate breast reconstruction.

 

References:

1. Gruber RP, Kahn RA, Lash H, Maser MR, Apfelberg DB, Laub DR. Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg. 1981;67(3):312-7.
2. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74(4):482-92.
3. Sbitany H. Important Considerations for Performing Prepectoral Breast Reconstruction. Plast Reconstr Surg. 2017;140(6S Prepectoral Breast Reconstruction):7S-13S.
4. Jones G, Yoo A, King V, et al. Prepectoral Immediate Direct-to-Implant Breast Reconstruction with Anterior AlloDerm Coverage. Plast Reconstr Surg. 2017;140(6S Prepectoral Breast Reconstruction):31S-38S.