Comparative Study of Prepectoral and Subpectoral Expander-Based Breast Reconstruction and Clavien IIIb Score Outcomes

Abstract

Background:Prepectoral breast reconstruction is increasingly popular. This study compares complications between 2 subpectoral and 1 prepectoral breast reconstruction technique.Methods:Between 2008 and 2015, 294 two-staged expander breast reconstructions in 213 patients were performed with 1 of 3 surgical techniques: (1) Prepectoral, (2) subpectoral with acellular dermal matrix (ADM) sling (“Classic”), or (3) subpectoral/subserratus expander placement without ADM (“No ADM”). Demographics, comorbidities, radiation therapy, and chemotherapy were assessed for correlation with Clavien IIIb score outcomes. Follow-up was a minimum of 6 months.Results:Surgical cohorts (n = 165 Prepectoral; n = 77 Classic; n = 52 No ADM) had comparable demographics except Classic had more cardiac disease (P = 0.03), No ADM had higher body mass index (BMI) (P = 0.01), and the Prepectoral group had more nipple-sparing mastectomies (P < 0.001). Univariate analysis showed higher expander complications with BMI ≥ 40 (P = 0.05), stage 4 breast cancer (P = 0.01), and contralateral prophylactic mastectomy (P = 0.1), whereas implant complications were associated with prior history of radiation (P < 0.01). There was more skin necrosis (P = 0.05) and overall expander complications (P = 0.01) in the Classic cohort, whereas the No ADM group trended toward the lowest expander complications among the 3. Multivariate analysis showed no difference in overall expander complication rates between the 3 groups matching demographics, mastectomy surgery, risks, and surgical technique.Conclusions:Prepectoral and subpectoral Classic and No ADM breast reconstructions demonstrated comparable grade IIIb Clavien score complications. BMI > 40, stage 4 cancer, and contralateral prophylactic mastectomy were associated with adverse expander outcomes and a prior history of radiation therapy adversely impacted implant outcomes. Ninety-day follow-up for expander and implant complications may be a better National Surgical Quality Improvement Program measure.

The largest multicentre data collection on prepectoral breast reconstruction: The iBAG study

“…In fact, Nahabedian reported very high infection rates (12.8% by patient; 8.1% by breast) not in line with iBAG study outcomes, while implant loss rate was similar (6.5%) and slightly different necrosis and seroma rates (9.7% and 4.8%) 17 . High implant and expander loss rate, as well as infection one, were also found in Bettinger and Schnarrs publications about prepectoral expander/implant reconstructions, with overall infection rates of 9.1% for the first one and 11.8% for the second, reinforcing again our hypothesis 20,21 …”

“…Furthermore, patient's risk factors revealed by our statistical analysis find confirmations in other publications: Schnarrs highlighted higher postoperative complications risk in smokers and patients with >500 g breasts, 20 while Bettinger observed increased complication rates in previously irradiated breasts and no significant association between chemotherapy and postoperative adverse events 21 …”

Selective pectoralis major muscle denervation in breast reconstruction: a technical modification for more effective and cosmetic results

“…Recently, the long-term results of clinical studies on the pre-pectoral reconstructions by means of a synthetic matrix were published (11,12). Several other studies reported similar results with biological matrixes (8,(13)(14)(15)(16)(17)(18)(19). A pre-pectoral approach showed, in all these series, a highly documented surgical safety, comparable to the standard full muscular coverage and to the dual-plane coverage.…”

Complication rates among women undergoing preventive mastectomy: An Austrian registry

“…This is in contrast to the results of some studies, which reported no significant difference between the two. [15][16][17] The notable difference in complication rates between sub-or prepectoral implant-based breast reconstruction may be attributed to the less invasive operative technique used in prepectoral implant-based breast reconstruction, which may also partially explain its increasing popularity.…”