Prepectoral Versus Subpectoral Tissue Expander Placement: A Clinical and Quality of Life Outcomes Study

Abstract

Background:Traditionally, tissue expanders (TEs) for breast reconstruction have been placed beneath the pectoralis major muscle with or without acellular dermal matrix. More recently, full acellular dermal matrix coverage has been described for prepectoral TE placement. Our study aims to explore differences in clinical and quality-of-life (QOL) outcomes for prepectoral versus subpectoral TE breast reconstruction.Methods:We identified patients who underwent postmastectomy breast reconstruction with prepectoral or subpectoral TE placement between 2011 and 2015 and completed QOL surveys. Primary outcomes were postoperative pain and QOL scores. Secondary outcomes were clinical outcomes. We used Wilcoxon rank-sum test, chi-square test, and linear regression to compare outcomes. Postoperative follow-up for each patient was at least 60 days, except that of pain scores, which were at least 30 days. Mean age was 49 ± 10 years.Results:Twenty-six prepectoral TE patients and 109 subpectoral TE patients met inclusion criteria. Pain scores were significantly lower at 12 hours, 1 day, 7 days, and 30 days postoperatively for the prepectoral group, compared with the subpectoral group, even after adjusting for confounding variables [PO12H: Sub-Pectoral (SP) median (interquartile range), 7 (5–8), Pre-Pectoral (PP), 5 (2.5–7.5), P value = 0.004; PO1D: SP, 5 (4–6), PP 3 (2–4), P value = < 0.001; PO7D: SP, 2 (0–4), PP, 0 (0–2), P value = 0.004; PO30D: SP, 0 (0–2), PP, 0 (0–0), P value = 0.039)]. Breast-Q scores were not significantly different between study groups. RAND-36 Physical Health scores were lower among prepectoral TE patients.Conclusions:Prepectoral TE breast reconstruction presents an opportunity to improve upon current reconstructive methods and does result in significantly lower pain scores. The associated risks have yet to be fully described and are important considerations, as these prepectoral patients had lower physical health outcome scores.

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

“…Overseas, studies have been published by American authors which have performed PPBR on larger cohorts, yet in a two‐stage procedure with the use of tissue expander covered with ADM positioned on the frontal part only 16 . Moreover, the use of porcine ADM is still uncommon among the main American scientific papers, so that most evidence derives from human dermis such as AlloDerm 17 .…”

Current Trends in Prepectoral Breast Reconstruction: A Survey of American Society of Plastic Surgeons Members

“…Recent reports have associated prepectoral reconstruction with improved pain scores and decreased analgesic requirements, and this assertion was supported by study participants. 17 – 19 Cosmetic outcomes of prepectoral reconstruction, although difficult to evaluate objectively, were also felt to be superior to outcomes of submuscular reconstruction by a majority of survey respondents. Participants cited factors such as “improved cleavage” and “more natural breast position” as significant considerations for choosing prepectoral reconstruction.…”

“…Previously reported surgeon assessments of cosmetic outcomes have supported these claims, 20 and patient-reported outcome data, while limited, suggest comparable or improved satisfaction with outcomes. 19 , 21 , 22 Free-text response data from survey participants also emphasized other factors driving the decision to offer prepectoral breast reconstruction, with the most common indication being prior or planned radiation (20.6%). Radiation is known to cause fibrosis and contraction of the pectoralis major muscle and is a known risk factor for implant malposition and reconstructive failure in implant-based reconstruction.…”

Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

“…Given that prepectoral dissection is less disruptive to the native anatomy of the chest wall, this type of reconstruction may lend itself to enhanced recovery as it has been reported to result in less pain and discomfort for the patient as compared with subpectoral reconstruction. 24…”