Review
A systematic review of complications in prepectoral breast reconstruction

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Summary

The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high incidence of capsular contracture and complication rates. With the introduction of acellular dermal matrix (ADM), plastic surgeons are again considering the advantages of prepectoral implant placement. A systematic review was conducted to examine complication profiles in prepectoral breast reconstruction alone versus prepectoral with ADM or mesh.

A systematic review of the PubMed database was performed from inception to March 2017 to identify literature on postmastectomy patients undergoing prepectoral breast reconstruction with and without ADM or mesh. Study characteristics, complication rates, and outcomes were extracted for analysis. Study quality was assessed using the Newcastle–Ottawa Scale, and complication profiles were analyzed using the random-effects model.

Twenty-seven studies met criteria for inclusion out of 550 identified for review. For 1881 total breasts, the complication rate with ADM was 23.4%, while the rate without an additional implant material was 27.5%. The difference in the capsular contracture rate with and without ADM was 2.3% and 12.4%, respectively.

The use of ADM in prepectoral breast reconstruction correlated with lower capsular contracture and overall complications rates; however, rates of implant loss, infection, and mastectomy flap necrosis were higher with the use of ADM. Results were variable across studies, and in general, the quality of evidence reported was low. Because the methodology for outcome assessment was inconsistent, there is a need for further investigation with comparative studies and standardized outcome reporting.

Introduction

The use of implants for reconstruction after mastectomy began over four decades ago when Snyderman and Guthrie first used the Cronin silicone implant for these procedures.1 Initially, implants were placed prepectorally, and only small sizes could be used to avoid excessive tension on the skin with the potential for skin necrosis or implant extrusion. In the decades following, there were numerous published reports of high complication rates with prepectoral placement of tissue expanders and implants, as well as high rates of capsular contracture.2, 3, 4, 5 These findings contributed to a paradigm shift away from prepectoral and toward submuscular implant placement.

Advantages of submuscular implant placement stem from the added layer of tissue between the implant and the mastectomy flap. These include additional protection against implant exposure in cases of wound breakdown, a decrease in visible rippling particularly with saline implants, and a proposed decreased rate of capsular contracture.2, 6 Drawbacks of the submuscular technique include deficiencies in upper pole contour, animation deformity, and increased postoperative pain and length of recovery secondary to muscle dissection.7, 8, 9

The introduction of acellular dermal matrix (ADM) in breast reconstruction in 2005 led to several improvements in submuscular reconstruction, including improved definition of the inframammary fold, decreased capsular contracture rates, prevention of implant migration, and decreased tension on mastectomy skin flaps leading to increased initial expansion volumes.10, 11, 12, 13, 14 However, the use of ADM did not address postoperative pain, recovery time, or animation deformity and may be associated with increased rates of infection and seroma.15, 16 Synthetic mesh products have also proven to be safe and effective in implant-based breast reconstruction to address the same problems as those with ADM but are used less frequently in the United States.17

Along with the use of ADM for implant coverage, many refinements in the techniques for oncologic resection and subsequent reconstruction have occurred since the first attempts at prepectoral reconstruction. In light of these advancements, prepectoral implant-based breast reconstruction has re-emerged as a viable surgical technique after skin or nipple-sparing mastectomy. Supporters posit that these procedures carry less morbidity and provide more natural-looking results. In addition, animation deformity is no longer an issue with prepectoral placement. According to the ASPS Plastic Surgery Statistics Report in 2015, over 106,000 breast reconstruction procedures were performed in the United States. Implant-based reconstructions were the most common procedures, and ADM was used in 53% of the surgeries.18 Despite this impressive scale, the current literature on prepectoral breast reconstruction with ADM is limited.

Systematic reviews on prepectoral breast reconstruction by Salibian et al. and Chatterjee et al. found relatively low pooled complication rates; however, follow-up times and complication rates across studies were inconsistent.19, 20 These reviews mainly included reconstructions incorporating the use of ADM or mesh; outcomes with and without additional implant material have not yet been reviewed. A systematic review was conducted to examine outcomes in postmastectomy patients undergoing breast reconstruction using prepectoral placement of TEs and implants, and then, the complication profiles with and without the use of ADM or synthetic mesh were compared.

Section snippets

Literature search

A broad search of the literature was performed using the PubMed database from inception to March 2017. The database was queried using the following search terms: “breast” and “implant” and “subcutaneous” or “sub-cutaneous” or “prepectoral” or “pre-pectoral.” In addition, the references of relevant studies were reviewed for potential inclusion.

Study selection and data extraction

Studies were considered eligible if they reported on outcomes and complications of breast reconstruction with prepectoral implant or tissue expander

Study characteristics

A total of 550 articles were identified using our search terms and inclusion criteria. After two levels of screening, 27 articles were identified for analysis in our systematic review (see Figure 1). The 27 studies included a total of 1881 breasts or procedures. The majority of articles reported complications according to the number of breasts, as we did in this review. When examining material for implant or tissue expander coverage, there were 893 breasts with ADM, 18 breasts with Vicryl mesh,

Discussion

After initial attempts at prepectoral placement of implants and TEs, there have been many developments that have led surgeons to re-examine prepectoral implant placement as a reconstructive option. These advancements include improved design of implants and TEs, intraoperative perfusion assessment technologies, and fat grafting to augment soft tissue between the skin flap and implant.26, 27, 28, 29, 30, 31 Form-stable silicone implants have been shown to be associated with lower rates of

Financial disclosures/commercial associations

None.

Sources of support/funding

None.

Conflict of interest

None.

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    Presented at: ASPS Plastic Surgery the Meeting on October 7th, 2017; Orlando, FL.

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