Reoperative Complications in 521 Prepectoral Breast Reconstructions Using Acellular Dermal Matrix: A Departmental Paradigm Shift

Purpose: Prepectoral breast reconstruction continues to gain ground as the new standard for non-autologous correction of surgical amastia. When compared to a subpectoral pocket, benefits include improved aesthetics, absence of animation deformity, decreased operative time and less postoperative pain.^1-3 Until now, comparisons between the two techniques have been relatively underpowered and subject to observer bias. In what is the largest sample size to date, this study seeks to compare the rates of reoperative complications between subpectoral and prepectoral breast reconstructions using human acellular dermal matrix (ADM).

Materials and Methods: A retrospective review of 7 surgeons performing staged implant-based breast reconstruction with tissue expansion from 2015 to 2017 was performed. Surgical technique included either subpectoral tissue expander placement with lower pole ADM sling or prepectoral reconstruction with ADM wrap. A complication was defined as any incident that required an unplanned return to the operating room. Patient demographics and comorbidities between the groups were assessed for outcome correlations.

Results: During this time period, 664 patients underwent staged expander reconstruction to total 1084 reconstructed breasts (n=563 subpectoral; n=521 prepectoral). Each surgeon performed both techniques, all having transitioned to prepectoral by the end of the collection period. There were no differences in patient demographics between the two groups, including BMI (p=0.93) and smoking status (p=0.19). Total complication rate requiring unplanned reoperation between subpectoral and prepectoral reconstructions were 21.7% and 20.0%, respectively (OR 0.98; 0.95 CI 0.73-1.32, p=0.92). More specifically, no significant difference was found for rates of hematoma (OR 1.39; 0.95 CI 0.62-3.08, p=0.42), infection (OR 1.04; 0.95 CI 0.70-1.56, p=0.84), exposure (OR 0.95; 0.95 CI 0.60-1.50, p=0.82) or seroma (OR 0.54; 0.95 CI 0.16-1.80, p=0.31) between the subpectoral and prepectoral techniques. Smoking did significantly increase the risk of reoperation across all reconstructions (OR 1.48; 0.95 CI 1.01-2.16, p=0.042).

Conclusions: Staged prepectoral breast reconstruction is a safe technique that does not impart a higher unplanned reoperation rate than traditional subpectoral expander placement. Smoking continues to be a proven risk factor for surgical complications and cannot be reiterated enough to patients. Adoption of the prepectoral plane has been universally embraced across our plastic surgery department.

1. Sbitany, Hani, et al. Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy. Plastic and Reconstructive Surgery, vol. 140, no. 3, 2017, pp. 432–443
2. Nahabedian, Maurice Y., and Costanza Cocilovo. Two-Stage Prosthetic Breast Reconstruction: A Comparison Between Prepectoral and Partial Subpectoral Techniques. Plastic and Reconstructive Surgery, vol. 140, 2017, 22S-30S
3. Cattelani L, Polotto S, Arcuri MF, Pedrazzi G, Linguadoca C, Bonati E. One-Step Prepectoral Breast Reconstruction With Dermal Matrix-Covered Implant Compared to Submuscular Implantation: Functional and Cost Evaluation. Clin Breast Cancer. 2017 Dec 2