Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

Abstract

Background: Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement. Methods: A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes. Results: A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange. Conclusions: Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. Clinical Question/Level of Evidence: Therapeutic, III.

Implant-based Breast Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis

“…Other complications were reported by one NRCS each. Avila et al 15 reported lower analgesic use with prepectoral implants ( P = 0.03; no adjusted effect size reported). Avila et al 15 also reported comparable risk of unplanned repeat surgeries for revision ( P = NS), although no adjusted effect size was reported.…”

“…Avila et al 15 reported lower analgesic use with prepectoral implants ( P = 0.03; no adjusted effect size reported). Avila et al 15 also reported comparable risk of unplanned repeat surgeries for revision ( P = NS), although no adjusted effect size was reported. Nealon et al 37 reported comparable risks of necrosis (adjOR = 1.01, 95% CI 0.74–5.95), explantation (adjOR = 1.01, 95% CI 0.07 to 14.1), capsular contracture (adjOR = 0.30, 95% CI 0.03 to 1.55), and seroma (adjOR = 1.49, 95% CI 0.37–6.11).…”

“…We included eight studies (one RCT, 11 and seven NRCSs reported in eight articles 15 , 16 , 18 , 24 , 28 , 29 , 38 , 39 ) that compared prepectoral, partial submuscular, and total submuscular planes of implant placement in 1555 patients. We rated the RCT as having a moderate risk of bias, six of the seven NRCSs at a high risk, and one NRCS at a moderate risk.…”

“…Surgical Complications: Two NRCSs (Nealon et al 37 Although no adjusted effect sizes were reported, two NRCSs (Avila et al 15 and Cattelani et al 18 ) reported inconsistent results regarding pain (See table 4-5, Supplemental Digital Content 4, http://links.lww.com/PRSGO/B953). Avila et al 15 used a visual analog scale (VAS) and reported no statistically significantly difference in pain levels.…”

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction

“… 58 , 59 Thus, these techniques cannot be assessed in this trial, and the results’ applicability to such techniques is uncertain. According to recent studies, 60 , 61 , 62 , 63 , 64 , 65 , 66 however, the prepectoral position (which, in principle, always includes some type of mesh) renders no higher SSI rates compared with the subpectoral position, so multiple-dose antibiotic prophylaxis is probably not indicated.…”