Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions

Gabriel, Allen; Sigalove, Steven; Sigalove, Noemi; Storm-Dickerson, Toni; Rice, Jami; Pope, Nicole; Maxwell, G. Patrick

doi:10.1093/asj/sjx261

Cited by 74 publications

(89 citation statements)

References 23 publications

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“…Since employing this technique, our rate of capsular contracture has dropped to 0%. Our findings are supported by Gabriel et al who similarly found complete resolution of animation deformity and no incidence of capsular contracture with ADM use in their large series (10).…”

Section: Discussionsupporting

confidence: 90%

“…As such, implant pocket conversion from the submuscular to prepectoral plane has become our preferred method of addressing animation deformity. Additionally, when performed in conjunction with fat grafting and ADM coverage, implant pocket change to the prepectoral plane has been shown to produce optimal aesthetic results without animation deformity recurrence (8)(9)(10). In this study, we review our series of patients who have undergone implant pocket change for correction of animation deformity.…”

Section: Introductionmentioning

confidence: 99%

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Correction of animation deformity with subpectoral to prepectoral implant exchange

2019

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Background: Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. Methods: We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Results: Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Conclusions: Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Correction of animation deformity with subpectoral to prepectoral implant exchange

2019

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“…Pocket change to the prepectoral space typically involves detachment and reinsertion of the pectoralis to the chest wall (with or without anterior capsulectomy), creation of a neo-pocket in the subcutaneous plane, and prepectoral implant placement with ADM/mesh reinforcement similar to primary reconstruction cases. Series on prepectoral revisions have reported resolution of animation deformity in the vast majority of cases with low complication rates (58,59).…”

Section: Subpectoral To Prepectoralmentioning

confidence: 99%

Strategies and considerations in selecting between subpectoral and prepectoral breast reconstruction

Salibian¹,

Frey²,

Karp³

2019

Gland Surg

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Implant-based breast reconstruction has evolved through advances in mastectomy and reconstruction techniques to offer excellent outcomes with both prepectoral and subpectoral implant placement. Proper patient selection and surgical technique are key for optimizing outcomes and minimizing complications regardless of implant location. Therefore, familiarity with the benefits and limitations of each technique is vital. Several patient characteristics, such as history of significant comorbidities, radiation or active smoking, portend higher risk of complications with prepectoral reconstruction, in which case subpectoral implant placement may be a safer option. Oncologic consideration such as location and size of tumors also play an important role in determining the appropriate technique. The most critical factor in the success of prepectoral reconstruction is the quality of mastectomy flaps. Thorough intraoperative evaluation of mastectomy flap perfusion and viability will determine whether immediate prepectoral reconstruction is possible or other alternatives such as subpectoral or delayed prepectoral techniques should be considered. Discussing these factors with patients preemptively as well as developing a coordinated plan with the patient and oncologic surgeon will maximize success in both subpectoral and prepectoral implant-based reconstruction.

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“…Subcutaneous fat grafting has been used extensively in both surgeons' practices (AK Antony, G Jones) in an effort to re-establish a gliding plane and ameliorate the disfigurement from animation deformity with limited success (35). Changing the position of reconstruction from the sub-pectoral to the pre-pectoral plane offers the opportunity to negate these effects, eliminating the distortion seen with sub-pectoral implant positioning (6,12,(36)(37)(38)(39)(40). With the limitations imposed by sub-pectoral breast reconstruction, and the confluence of scientific achievement, improvement in surgical technique and advances in technology, successful pre-pectoral direct to implant breast reconstruction has become a reality.…”

Section: Introductionmentioning

confidence: 99%

Single stage, direct to implant pre-pectoral breast reconstruction

Jones¹,

Antony²

2019

Gland Surg

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Background: Given the current trends in skin preservation during mastectomy, improved biofilm reduction algorithms, and advancements in tissue bioengineering and perfusion assessment, acellular dermal matrix (ADM)-reinforced single stage, direct to implant insertion in the pre-pectoral space has become a viable alternative to two-stage expander-based, sub-pectoral reconstruction. Methods: The authors performed a retrospective review of their pre-pectoral cases evaluating outcomes for all single stage, direct to implant procedures. Outcomes reviewed included hematoma, seroma, infection, device loss or change, animation deformity and revisional procedures such as fat grafting. The anterior tenting surgical technique is also reviewed. Results: The authors have carried out 305 direct to implant pre-pectoral breast reconstructions using an anterior tenting technique with low complication rates and superior clinical and functional outcomes. The benefits of this technique include less patient discomfort, no need for postoperative expansion, virtually no subjective negative impact on upper extremity function and elimination of animation deformity. Longerterm follow-up demonstrates maintenance of the integrity and quality of the reconstructions over time. Conclusions: The authors consider single stage, pre-pectoral direct to implant breast reconstruction to be a state-of-the-art breast reconstruction technique and have found it to be safe and reproducible. This technique is their primary choice for immediate implant-based reconstruction following mastectomy.

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Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions

Cited by 74 publications

References 23 publications

Correction of animation deformity with subpectoral to prepectoral implant exchange

Correction of animation deformity with subpectoral to prepectoral implant exchange

Strategies and considerations in selecting between subpectoral and prepectoral breast reconstruction

Single stage, direct to implant pre-pectoral breast reconstruction

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