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Two-stage prosthetic breast reconstruction with latissimus flap: Prepectoral versus subpectoral approach
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Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach Mustafa Akyurek MD, PhD , Samandar Dowlatshahi MD , Robert M. Quinlan MD PII: DOI: Reference:
S1748-6815(19)30489-9 https://doi.org/10.1016/j.bjps.2019.10.021 PRAS 6305
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
26 June 2019 20 October 2019
Please cite this article as: Mustafa Akyurek MD, PhD , Samandar Dowlatshahi MD , Robert M. Quinlan MD , Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.10.021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach
Mustafa Akyurek, MD, PhD, Samandar Dowlatshahi, MD* Robert M. Quinlan, MD
From Division of Plastic Surgery and Surgical Oncology at University of Massachusetts Medical School, Worcester, Massachusetts and Division of Plastic Surgery* at BethIsrael Deaconnes Medical Center, Harvard Medical School, Boston, Massachusetts.
Correspondence to: Mustafa Akyurek, MD, PhD Associate Professor of Surgery Division of Plastic Surgery University of Massachusetts Medical School Worcester, Massachusetts [email protected]
1
Prepectoral vs Subpectoral
Summary Background: Latissimus flap with prosthetic breast reconstruction after mastectomy is an established method, particularly in patients who have failed breast conserving therapy. This study presents comparison of prepectoral and subpectoral approach for two-stage prosthetic breast reconstruction with latissimus flap. Methods: A retrospective review of outcomes and complications was completed between the prepectoral group (n= 33 patients, 50 reconstructed breasts) and subpectoral group (n= 22 patients, 36 reconstructed breasts). Results: The demographics were similar between the prepectoral and subpectoral groups in terms of mean age (52.4 vs 52.5 years, p= 0.97), smoking history (15.1 vs 13.6 percent; p=1.00), radiation history (75.8 vs 91.0 percent; p=0.28), and mean length of follow up (479 vs 680 days; p=0.07). The body mass index was significantly higher in the prepectoral group (27.6 vs 25.2 kg/m2; p=0.03).
Complications were similar
between the groups in terms of hematoma (9.1 vs 0.0 percent, p=0.26), infection resulting in implant failure (9.1 vs 4.5 percent, p=0.64), thromboembolic events (3.0 vs 4.5 percent, p=1.0), donor site seroma (66.7 vs 40.9 percent, p=0.09), breast seroma (18.2 vs 27.3 percent, p=0.51), capsular contracture (9.1 vs 4.5 percent, p=0.64), animation deformity (39.4 vs 50.0 percent, p=0.58) and reoperation (24.2 vs 22.8 percent, p=1.00). Patient satisfaction scores were also similar between the groups (4.33 ± 1.08 vs 4.14 ± 1.13, p= 0.52). Conclusions: Prepectoral approach for two-stage immediate prosthetic reconstruction with latissimus flap results in similar outcomes and complications compared to the
2
Prepectoral vs Subpectoral
subpectoral approach, yet obviating the need for any pectoralis major muscle dissection.
The use of prosthetic devices remains the most common method of breast reconstruction following mastectomy.1 Patients who have undergone previous radiation traditionally have been discouraged from implant-only breast reconstruction, given a poor complication profile such as implant failure and capsular contracture although the incidence of such complications varies widely across institutions.2-5 Latissimus dorsi myocutaneous flap remains a reliable choice in breast reconstruction, particularly in patients who failed breast conserving therapy requiring salvage mastectomy as it has been shown that use of autologous tissue with implant significantly reduces incidence of reconstructive failure in previously irradiated fields.2-7 Despite its drawbacks of visible donor site scar, seroma formation, and the need for an implant or fat grafting to achieve volume, the flap offers an excellent source of vascularized muscle sling to shape the breast mound as well as a skin island to create nipple areola complex.8 A subpectoral pocket has been advocated for coverage of the implant with the use of the latissimus flap by several authors.9-13 However, others14-18 questioned the necessity of the pectoralis major muscle dissection and it remains unknown whether there is any difference between the two techniques in terms of outcomes. The purpose of this study is therefore to compare outcomes and complications between the subpectoral and the prepectoral approach of two-stage prosthetic immediate breast reconstruction with latissimus flap.
3
Prepectoral vs Subpectoral
METHODS A
retrospective
study was performed identifying all immediate breast
reconstructions after mastectomy that were performed at an academic medical center between January of 2009 and December of 2016, utilizing a two-stage reconstruction of tissue expander and permanent implant along with latissimus dorsi myocutaneous flap. In this practice, patients with history of radiation who needed mastectomy were treated with either free autologous tissue transfer or Latissimus flap and two-stage prosthetic reconstruction. Therefore, this series included mainly patients who had failed breast conserving therapy requiring salvage mastectomy. Delayed reconstructions as well as cases of latissimus flap-only without implants were excluded. Data extracted included patient demographics, surgical technique, length of follow up, outcomes and complications. Patients were informally asked to evaluate the aesthetic result at a follow up visit at least 6 months following completion of reconstruction. For statistical analysis, two-tailed Fisher’s exact probability test was used for comparison of nominal variables. A two sample, two-tailed t-test for independent samples was used for measurement variables. The institutional review board of our academic center approved this study. Operative Technique The latissimus skin island was marked preoperatively. It was islandized followed by muscle dissection in its entirety. The flap’s insertion was then divided approximately 80 percent to maximize mobility and allow for a tension-free inset. The thoracodorsal nerve was cut to minimize animation deformity. Following skin sparing mastectomy and
4
Prepectoral vs Subpectoral
any additional axillary node biopsy, the flap was transposed to the mastectomy defect. Mastectomy portion of the case was performed by an oncologic surgeon. In the subpectoral group, the pectoralis major muscle was dissected and a tissue expander (Mentor Siltex anatomically shaped, medium height, range 275 to 700 ml) was placed in the subpectoral pocket and the latissimus flap covered the inferolateral aspect of the implant. Whereas in the prepectoral group, the latissimus flap covered the entirety of the tissue expander without any pectoralis major muscle dissection (Figure 1). In both groups, the tissue expander was secured to the inframammary fold and medial breast border by securing its suture tab with 2-0 polyglactin suture and the skin paddle was then inset vertically into the mastectomy skin defect. Intraoperatively, the
tissue
expander was filled with saline as tolerated by the soft tissues. The authors did not use any acellular dermal matrix products in any of the cases in this series. All patients received perioperative intravenous antibiotics for 24 hours. Following full expansion to the desired volume postoperatively, a second stage surgery was performed, typically about 3 months later, with exchange to a permanent implant as well as implant pocket modification as needed. Implant reconstruction was accomplished with Mentor smooth round gel implant (range, moderate to high profile) or Mentor smooth round saline implant (range, moderate to high profile). RESULTS A total of 86 breast reconstructions were performed in 55 consecutive patients (Figures 2 to 5). The indication for use of latissimus flap in combination with prosthetic reconstruction was history of failed breast conservation treatment in the majority of the patients (81.8 percent).
5
Prepectoral vs Subpectoral
In subpectoral group, representing the earlier experience, there were 36 consecutive reconstructions in 22 patients. The prepectoral approach was then used for 50 consecutive reconstructions in 33 patients. The demographics between the prepectoral and subpectoral groups were similar in terms of age (52.4 ± 8.6 years vs 52.5 ± 12.1 years; p>0.05), smoking history (15.1 vs 13.6 percent; p>0.05), radiation history (75.8 vs 91.0 percent; p>0.05), and length of follow up (479 ± 326 vs 680 ± 494 days; p>0.05). The body mass index, however, was found to be significantly higher in the prepectoral group (27.6 ± 4.3 vs 25.2 ± 3.2 kg/m2; p<0.05) (Table 1). Total tissue expander fill volume was similar between the prepectoral and subpectoral groups (p>0.05; 518.2 ± 138.4 ml vs 482.3 ± 130.5 ml). Likewise, there was no statistically significant difference in terms of the mean implant sizes (p>0.05; 482.5 ±124.2 ml vs 470.5 ± 114.7 ml). Length of hospital stay was similar between the prepectoral and subpectoral groups (p>0.05; 2.2 ± 0.6 days vs 2.4 ± 0.5 days). Complications were observed at a similar rate between the two groups (Table 2). Three patients (9.1 percent) developed donor site hematoma in the prepectoral group as compared to none in the subpectoral group, with no statistically significant difference. There was no evidence of difference in terms of thromboembolic events; one patient (3.0 percent) developed deep vein thrombosis in the prepectoral group while a non-fatal incidence of pulmonary embolism was noted in one patient (4.5 percent) in the subpectoral group. Infections requiring reoperation which finally lead to a failure of reconstruction with removal of the tissue expander occurred in three patients (9.1 percent) in the prepectoral group and in one patient (4.5 percent) in the subpectoral
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Prepectoral vs Subpectoral
group. This difference was not statistically significant. In both groups, seromas of the reconstructed breast were found in 6 patients (18.2 vs 27.3 percent), managed by needle drainage around the expander port. There were no cases of implant exposure in either group. Most common complication was donor site seroma in this series, noted in 66.7 percent of patients in the prepectoral and 40.9 percent in the subpectoral group, with no statistically significant difference. Animation deformity with Latissimus muscle twitching was observed at a similar rate between the groups, noted in 13 patients (39.4 percent) in the prepectoral groups as opposed to 11 patients (50.0 percent) in the subpectoral groups with no statistically significant difference. Revision rate between the groups was similar as well; 8 patients in the prepectoral group (24.2 percent) and 5 patients in the subpectoral group (22.8 percent) underwent autologous fat grafting to correct contour irregularities without any statistically significant difference. When asked to informally evaluate the aesthetic outcome at follow up (5= excellent, 4= good, 3= fair, 2= mediocre, 1= poor), patient satisfaction scores were similar between the two groups (4.33 ± 1.08 vs 4.14 ± 1.13, p= 0.52), with no statistically significant difference (Table 3). DISCUSSION Latissimus dorsi flap breast reconstruction can be accomplished satisfactorily in one stage implant placement.19-22 Since majority of the patients in this series had prior radiation treatment associated with breast conservation therapy, presenting for salvage mastectomy with reconstruction, we elected to employ a two-stage prosthetic reconstruction with the latissimus flap. This is based on previous published work,6,10-18 particularly related to similar clinical scenario of prior radiation treatment,6,11,18
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Prepectoral vs Subpectoral
suggesting improved outcomes with two-stage expander/implant reconstruction with latissimus flap compared to a single stage procedure. Hammond14 and others6,11,16 emphasized that there is inevitable tissue swelling from the latissimus myocutaneous flap and therefore it is a difficult task to predict how much of this swelling will recede in order to determine the correct size of the implant in a one stage procedure. Moreover, swelling can also cause inordinate pressure on the mastectomy flaps given that an implant large enough to provide the desired volume is placed primarily, resulting in potential ischemia and possible necrosis of the mastectomy skin flap.14 Others13 raised the concern related to muscle atrophy that may develop months after the flap procedure, resulting in a smaller breast than initially designed for. Such difficulties can be eliminated by placing a tissue expander instead of an implant.
6,10-18
Even if the
device simply functions as a spacer, it allows the soft tissues to settle around it such that the contours of the breast can be assessed and manipulated as needed to provide the optimal result.14 Freeman et al.11 and Losken et al.16 stated that the presence of a tissue expander may be beneficial to oppose some of the contractile forces present early in the healing process, resulting in a softer capsule. Others14,16 reported that capsular contracture rates are lower and cosmetic results are more predictable with the two-staged procedure with latissimus flap. The authors14,16 reasoned that patients essentially undergo a capsulotomy at the time of exchange procedure which may be beneficial particularly in the setting of breast irradiation, along with other procedures of fine tuning that allows for creation of a breast with greater ptosis and more natural contours. Therefore, a two-stage prosthetic reconstruction was generally recommended
8
Prepectoral vs Subpectoral
with latissimus flap, with more consistent and generally more favorable results compared to primary implant placement.6, 10-18 Our experience, as well as previous work,10,11 proved that careful dissection of the latissimus muscle along its anatomic borders, to the level of thoracolumbar fascia caudally along with division of majority of its insertion allows for a large surface area of the muscle and unrestricted transposition to the chest, allowing complete coverage of a prosthetic device in its prepectoral position. In immediate breast reconstruction, this then begs the question whether pectoralis major muscle elevation is necessary since the prosthetic device can easily be covered completely by the latissimus flap. The ideal location for prosthetic devices in implant-only breast reconstruction has recently become a topic of discussion.12-16 Although several studies have been published comparing the subpectoral and prepectoral
placement in implant-only
prosthetic reconstruction, typically with the use of acellular dermal matrix products,13,14 to the best of our knowledge, our study is the first to report head to head comparison of the two approaches in two-stage prosthetic reconstruction with latissimus flap. In our study, we found that the rate of major complications were similar between the two groups. Most common complication was donor site seroma; although it was noted at a higher rate in the prepectoral group compared to the sub pectoral group, the difference was not statistically significant. Generally, donor site fluid collection following latissimus flap harvesting is not uncommon, ranging from 6 to 80 percent.17-21 The incidence appears to correlate with age, body mass index, flap size, and presence of concomitant lymphadenectomy.22,23 Our prepectoral cohort did have a significantly higher body mass index than the subpectoral cohort, which could be a factor for the
9
Prepectoral vs Subpectoral
reported difference. Several measures have been advocated in an attempt to mitigate this risk, such as quilting and progressive tension sutures and fibrin sealants. 24-26 Although prepectoral implant-only breast reconstruction is gaining popularity, showing promising data in cases with post mastectomy radiation following prepectoral acellular
dermal
matrix
coverage,27
literature
shows
evidence
of
increased
complications
in patients with prior history of radiation using implant-based breast
reconstruction,
2-5
including clinical experience with the prepectoral acellular dermal
matrix-only coverage.28 In fact, Gabriel and Maxwell 28 reported that they would not offer the prepectoral approach to those patients who have had radiation, given the increased risk of complications, unless the latissimus flap would also be utilized. Based on this study,
the
prepectoral approach for
prosthetic breast
reconstruction with latissimus flap is as safe and effective as the subpectoral technique. With similar complication rates and patient satisfaction, it does offer the advantage of avoiding pectoralis major muscle dissection. Furthermore, the subpectoral pocket is reserved for future site change should it become necessary such as in case of development of capsular contracture. Moreover, the prepectoral approach allows the breast borders to be precisely defined by suturing the muscle to the chest wall where it is considered aesthetically ideal, without being limited by the pectoralis muscle origin. We realize that this study has some limitations; both series were historical ones. The selection process between the two groups was inevitably time driven rather than random, namely, an evolution in practice from subpectoral to prepectoral. Therefore, there may be an uncontrollable variable of improvement in technique on the part of the surgeon although we did not modify any technical aspect over time. Finally, the number
10
Prepectoral vs Subpectoral
of patients studied were limited and as such higher number of cases in each group would increase the power of statistical analysis and conclusions drawn.
Conflict of interest statement The authors have no conflict of interest or funding. The institutional review board of our academic center approved this study. REFERENCES 1.
Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in US breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131: 15-23.
2.
Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: An update. Plast Reconstr Surg 2017; 140: 60S-68S.
3.
Lee KT, Mun GH. Prosthetic breast reconstruction in previously irradiated breasts: a meta analysis. J Surg Oncol 2015; 112: 468-475.
4.
Chen TA, Momeni A, Lee GK. Clinical outcomes in breast cancer expanderimplant reconstructive patients with radiation therapy. J Plast Reconstr Aesthet Surg 2016; 69: 14-22.
5.
Kearney AM, Brown MS, Soltanian HT. Timing of radiation and outcomes in implant based breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68: 1719-1726.
6.
Disa JJ, McCarthy CM, Mehrara BJ, et al. Immediate latissimus dorsi/prosthetic breast
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lumpectomy/radiation. Plast Reconstr Surg 2008; 121: 159e-164e.
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7.
Fisher JP, basta MN, Shubinets V, et al. A systematic meta analysis of prosthetic based breast reconstruction in irradiated fields
with or without autologous
muscle flap coverage. Ann Plast Surg 2016; 77: 129-134. 8.
Warren, A.G., et al., Breast reconstruction in a changing breast cancer treatment paradigm. Plast. Reconstr. Surg. 2008; 121: 1116-26.
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Schneider WJ, Hill HL, Brown RG. Latissimus doors myocutaneous flap for breast reconstruction. Br. J. Plast. Surg. 1977; 30: 277-281.
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Sternberg E, Perdikis G, McLaughlin S, Terkonda S, Waldorf J. Latissimus dorsi flap remains an excellent choice for breast reconstruction. Ann. Plast. Surg. 2006; 56: 31-35.
11.
Freeman M, Perdikis G, Sternberg E, Terkonda S, Waldorf J. Latissimus dorsi reconstruction: a good option for patients with failed breast conservation therapy. Ann. Plast. Surg. 2006; 57: 134-137.
12.
Elliott F, Ghazi B, Otterburn D. The scarless latissimus dorsi flap for full muscle coverage in device-based immediate breast reconstruction: An autologous alternative to acellular dermal matrix. Plast. Reconstr. Surg. 2011; 128: 71-79.
13.
Feng J, Pardoe C, Mota AM, Chui CHK, Tan BK. Two-stage latissimus dorsi flap with implant for unilateral breast reconstruction: getting the size right. Arch. Plast. Surg. 2016; 43; 197-203.
14.
Hammond DC. Latissimus dorsi flap breast reconstruction. Plast. Reconstr. Surg. 2009; 124: 1055-1063.
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15.
Pacella, S.J., et al., Aesthetic and technical refinements in latissimus dorsi implant breast reconstruction: a 15-year experience. Aesth. Surg. J. 2011; 31: 190-9.
16.
Losken A, Nicholas C, Pinell X, Carlson G. Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps. Ann. Plast. Surg. 2010; 65: 17-22.
17.
Yezhelyev M, Duggal C, Carlson G, Losken A. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann. Plast. Surg. 2013; 70: 557-562.
18.
Spear S, Boehmler J, Taylor N, Prada C. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Plast. Reconstr. Surg. 2007; 119: 1-9.
19.
DeLong M, Tandon V, Rudkin G, Da Lio A. Latissimus dorsi flap breast reconstruction-a nationwide inpatient sample review. Ann. Plast. Surg. 2017; 78: S185-S188.
20.
Chang D, Barnea Y, Robb G. Effects of an autologous flap combined with an implant
for
breast
reconstruction:
An
evaluation
of
1000
consecutive
reconstructions of previously irradiated breasts. Plast. Reconstr. Surg. 2008; 122: 356-362. 21.
Munhoz AM, Aldrighi C, Montag E, Arruda EG, Aldrighi JM, Filassi JR, Ferreria MC. Periareolar skin sparing mastectomy and latissimus dorsi flap with biodimensional expander implant reconstruction: surgical planning, outcomes, and complications. Plast. Reconstr. Surg. 2007: 119: 1637-1649.
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Prepectoral vs Subpectoral
22.
Smith BK, Cohen BE, Biggs TM, Suber J. Simultaneous bilateral breast reconstruction using latissimus dorsi myocutaneous flaps: A retrospective review of an institutional experience. Plast. Reconstr. Surg. 2011; 108: 1174-1181.
23.
Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant based breast reconstruction: rationale, indications and preliminary results. Plast Reconstr Surg 2017; 139: 287-294.
24.
Nahabedian MY, Cocilovo C. Two-stage prosthetic breast reconstruction: A comparison between prepectoral and partial subpectoral techniques. Plast Reconstr Surg 2017; 140: 22S-30S.
25.
Walia GS, Aston J, Bello R, et al. Prepectoral versus subpectoral tissue expander placement: A clinical and quality of life outcomes study. Plast Reconstr Surg Glob Open 2018; 6: e1731.
26.
Payday KZ, Wirth GA, Mowlds DS. Prepectoral breast reconstruction with fenestrated acellular dermal matrix: A novel design. Plast Reconstr Surg Glob Open 2018; 6: e1712.
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Wazir U, Mokbel K. The evolving role od prepectoral ADM-assisted implantbased immediate breast reconstruction following skin-sparing mastectomy. Am J Surg 2018, https://doi.org/10.1016/j.amjsurg.2018.01.021
28.
Schwabegger, A., et al., Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg, 1997; 38: 594-7.
29.
Delay, E., et al., Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg, 1998; 102: 1461-78.
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30.
Roy, M.K., et al., Complications of latissimus dorsi myocutaneous flap breast reconstruction. Eur J Surg Oncol, 1998; 24: 162-5.
31.
Menke, H., M. Erkens, and R.R. Olbrisch, Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg, 2001; 47: 107-14.
32.
Clough, K.B., et al., Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg, 2002; 109: 1904-11.
33.
Randolph, L.C., et al., Prediction of postoperative seroma after latissimus dorsi breast reconstruction. Plast Reconstr Surg, 2005; 116: 1287-90.
34.
Jeon, B.J., et al., Risk factors for donor-site seroma formation after immediate breast reconstruction with the extended latissimus dorsi flap: a statistical analysis of 120 consecutive cases. Ann Plast Surg, 2012; 69: 145-7.
35.
Daltrey, I., et al., Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation. Br J Surg, 2006; 93: 825-30.
36.
Rios, J.L., T. Pollock, and W.P. Adams, Jr., Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg, 2003; 112: 1779-83.
37.
Titley, O.G., G.E. Spyrou, and M.F. Fatah, Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg, 1997; 50: 106-8.
38.
Sbitany H, Gomez-Sanchez C, Piper M, Lentz R. Prepectoral breast reconstruction in the setting of postmastectomy radiation therapy: An assessment of clinical outcomes and benefits. Plast Reconstr Surg. 2019; 143: 10-20.
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Prepectoral vs Subpectoral
39.
Gabriel A, Maxwell P. Prepectoral breast reconstruction in challenging cases. Plast Reconstr Surg. 2017; 140: 14S-21S.
LEGENDS FOR FIGURES
Figure 1. Intraoperative view of the complete coverage of the implant by the latissimus muscle with prepectoral technique.
16
Prepectoral vs Subpectoral
Figure 2. A 62-year-old patient with previous history of failed bilateral breast conserving therapy presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at 3 years after exchange of 550 cc tissue expanders with 550 cc and 450 cc moderate plus profile smooth round gel implants, respectively, and bilateral nipple reconstruction.
17
Prepectoral vs Subpectoral
Figure 3. A 42-year-old patient with recurrent right breast cancer following lumpectomy and radiation presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at 2 years. Patient has 550 cc moderate plus profile smooth round gel implants after exchange with 550 cc tissue expanders.
18
Prepectoral vs Subpectoral
19
Prepectoral vs Subpectoral
Figure 4. A 45-year-old patient with left invasive ductal carcinoma presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at one year after exchange of bilateral breast tissue expanders (550 cc) with permanent gel implants (500 cc moderate plus profile smooth surface round) as well as bilateral nipple reconstruction.
20
Prepectoral vs Subpectoral
Figure 5. A 63-year-old patient presented with recurrent right breast cancer. Patient had history of bilateral lumpectomy for cancer, axillary node dissection, and radiation treatment 7 and 14 years previously, respectively. Bilateral skin sparing mastectomy was performed with two-stage subpectoral prosthetic breast reconstruction using latissimus flap. A. Preoperative view. B. Postoperative view at 3 years after exchange of 550 cc medium height tissue expanders with 550 cc moderate plus profile smooth surface gel implant bilaterally.
Characteristic Number of patients
21
Prepectoral
Subpectoral
P value
33
22
NA
Prepectoral vs Subpectoral
Number of reconstructed breasts
50
36
NA
Age (years; mean ± SD)
52.4 ± 8.6
52.5 ± 12.1
0.97
Body mass index (kg/m2; mean ± SD)
27.6 ± 4.3
25.2 ± 3.2
0.03*
Smoking history (%)
5 (15.1)
3 (13.6)
1.00
Radiation history (%)
25 (75.7)
20 (90.9)
0.28
Length of follow up (days; mean ± SD)
479 ± 326
680 ± 494
0.07
Length of hospital stay (days; mean ± SD)
2.2 ± 0.6
2.4 ± 0.5
0.20
Table 1. Patient characteristics. SD denotes standard deviation. NA indicates non applicable. Statistically significant results are shown with * label.
Complication
Prepectoral (%) Subpectoral (%)
P value
Hematoma
3 (9.1)
0 (0.0)
0.26
Infection resulting in implant failure
3 (9.1)
1 (4.5)
0.64
Thromboembolic events
1 (3.0)
1 (4.5)
1.00
Donor site seroma
22 (66.7)
9 (40.9)
0.09
Breast seroma
6 (18.2)
6 (27.3)
0.51
Capsular Contracture
3 (9.1)
1 (4.5)
0.64
22
Prepectoral vs Subpectoral
Animation Deformity
13 (39.4)
11 (50.0)
0.58
Reoperation with fat grafting
8 (24.2)
5 (22.8)
1.00
Table 2. Complications.
Patient Satisfaction Score
Prepectoral (%)
Subpectoral (%)
5 (excellent)
21 (63.6)
12 (54.6)
4 (good)
6
(18.2)
4
(18.2)
3 (fair)
3
(9.1)
3
(13.6)
2 (mediocre)
2
(6.1)
3
(13.6)
1 (poor)
1
(3.0)
0
(0.0)
Mean ± SD
4.33 ± 1.08
4.14 ± 1.13
Table 3. Patient satisfaction. SD denotes standard deviation. There was no statistically significant difference between the groups (p= 0.52)
23
Prepectoral vs Subpectoral
Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach Mustafa Akyurek MD, PhD , Samandar Dowlatshahi MD , Robert M. Quinlan MD PII: DOI: Reference:
S1748-6815(19)30489-9 https://doi.org/10.1016/j.bjps.2019.10.021 PRAS 6305
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
26 June 2019 20 October 2019
Please cite this article as: Mustafa Akyurek MD, PhD , Samandar Dowlatshahi MD , Robert M. Quinlan MD , Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.10.021
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Two-Stage Prosthetic Breast Reconstruction with Latissimus Flap: Prepectoral versus Subpectoral Approach
Mustafa Akyurek, MD, PhD, Samandar Dowlatshahi, MD* Robert M. Quinlan, MD
From Division of Plastic Surgery and Surgical Oncology at University of Massachusetts Medical School, Worcester, Massachusetts and Division of Plastic Surgery* at BethIsrael Deaconnes Medical Center, Harvard Medical School, Boston, Massachusetts.
Correspondence to: Mustafa Akyurek, MD, PhD Associate Professor of Surgery Division of Plastic Surgery University of Massachusetts Medical School Worcester, Massachusetts [email protected]
1
Prepectoral vs Subpectoral
Summary Background: Latissimus flap with prosthetic breast reconstruction after mastectomy is an established method, particularly in patients who have failed breast conserving therapy. This study presents comparison of prepectoral and subpectoral approach for two-stage prosthetic breast reconstruction with latissimus flap. Methods: A retrospective review of outcomes and complications was completed between the prepectoral group (n= 33 patients, 50 reconstructed breasts) and subpectoral group (n= 22 patients, 36 reconstructed breasts). Results: The demographics were similar between the prepectoral and subpectoral groups in terms of mean age (52.4 vs 52.5 years, p= 0.97), smoking history (15.1 vs 13.6 percent; p=1.00), radiation history (75.8 vs 91.0 percent; p=0.28), and mean length of follow up (479 vs 680 days; p=0.07). The body mass index was significantly higher in the prepectoral group (27.6 vs 25.2 kg/m2; p=0.03).
Complications were similar
between the groups in terms of hematoma (9.1 vs 0.0 percent, p=0.26), infection resulting in implant failure (9.1 vs 4.5 percent, p=0.64), thromboembolic events (3.0 vs 4.5 percent, p=1.0), donor site seroma (66.7 vs 40.9 percent, p=0.09), breast seroma (18.2 vs 27.3 percent, p=0.51), capsular contracture (9.1 vs 4.5 percent, p=0.64), animation deformity (39.4 vs 50.0 percent, p=0.58) and reoperation (24.2 vs 22.8 percent, p=1.00). Patient satisfaction scores were also similar between the groups (4.33 ± 1.08 vs 4.14 ± 1.13, p= 0.52). Conclusions: Prepectoral approach for two-stage immediate prosthetic reconstruction with latissimus flap results in similar outcomes and complications compared to the
2
Prepectoral vs Subpectoral
subpectoral approach, yet obviating the need for any pectoralis major muscle dissection.
The use of prosthetic devices remains the most common method of breast reconstruction following mastectomy.1 Patients who have undergone previous radiation traditionally have been discouraged from implant-only breast reconstruction, given a poor complication profile such as implant failure and capsular contracture although the incidence of such complications varies widely across institutions.2-5 Latissimus dorsi myocutaneous flap remains a reliable choice in breast reconstruction, particularly in patients who failed breast conserving therapy requiring salvage mastectomy as it has been shown that use of autologous tissue with implant significantly reduces incidence of reconstructive failure in previously irradiated fields.2-7 Despite its drawbacks of visible donor site scar, seroma formation, and the need for an implant or fat grafting to achieve volume, the flap offers an excellent source of vascularized muscle sling to shape the breast mound as well as a skin island to create nipple areola complex.8 A subpectoral pocket has been advocated for coverage of the implant with the use of the latissimus flap by several authors.9-13 However, others14-18 questioned the necessity of the pectoralis major muscle dissection and it remains unknown whether there is any difference between the two techniques in terms of outcomes. The purpose of this study is therefore to compare outcomes and complications between the subpectoral and the prepectoral approach of two-stage prosthetic immediate breast reconstruction with latissimus flap.
3
Prepectoral vs Subpectoral
METHODS A
retrospective
study was performed identifying all immediate breast
reconstructions after mastectomy that were performed at an academic medical center between January of 2009 and December of 2016, utilizing a two-stage reconstruction of tissue expander and permanent implant along with latissimus dorsi myocutaneous flap. In this practice, patients with history of radiation who needed mastectomy were treated with either free autologous tissue transfer or Latissimus flap and two-stage prosthetic reconstruction. Therefore, this series included mainly patients who had failed breast conserving therapy requiring salvage mastectomy. Delayed reconstructions as well as cases of latissimus flap-only without implants were excluded. Data extracted included patient demographics, surgical technique, length of follow up, outcomes and complications. Patients were informally asked to evaluate the aesthetic result at a follow up visit at least 6 months following completion of reconstruction. For statistical analysis, two-tailed Fisher’s exact probability test was used for comparison of nominal variables. A two sample, two-tailed t-test for independent samples was used for measurement variables. The institutional review board of our academic center approved this study. Operative Technique The latissimus skin island was marked preoperatively. It was islandized followed by muscle dissection in its entirety. The flap’s insertion was then divided approximately 80 percent to maximize mobility and allow for a tension-free inset. The thoracodorsal nerve was cut to minimize animation deformity. Following skin sparing mastectomy and
4
Prepectoral vs Subpectoral
any additional axillary node biopsy, the flap was transposed to the mastectomy defect. Mastectomy portion of the case was performed by an oncologic surgeon. In the subpectoral group, the pectoralis major muscle was dissected and a tissue expander (Mentor Siltex anatomically shaped, medium height, range 275 to 700 ml) was placed in the subpectoral pocket and the latissimus flap covered the inferolateral aspect of the implant. Whereas in the prepectoral group, the latissimus flap covered the entirety of the tissue expander without any pectoralis major muscle dissection (Figure 1). In both groups, the tissue expander was secured to the inframammary fold and medial breast border by securing its suture tab with 2-0 polyglactin suture and the skin paddle was then inset vertically into the mastectomy skin defect. Intraoperatively, the
tissue
expander was filled with saline as tolerated by the soft tissues. The authors did not use any acellular dermal matrix products in any of the cases in this series. All patients received perioperative intravenous antibiotics for 24 hours. Following full expansion to the desired volume postoperatively, a second stage surgery was performed, typically about 3 months later, with exchange to a permanent implant as well as implant pocket modification as needed. Implant reconstruction was accomplished with Mentor smooth round gel implant (range, moderate to high profile) or Mentor smooth round saline implant (range, moderate to high profile). RESULTS A total of 86 breast reconstructions were performed in 55 consecutive patients (Figures 2 to 5). The indication for use of latissimus flap in combination with prosthetic reconstruction was history of failed breast conservation treatment in the majority of the patients (81.8 percent).
5
Prepectoral vs Subpectoral
In subpectoral group, representing the earlier experience, there were 36 consecutive reconstructions in 22 patients. The prepectoral approach was then used for 50 consecutive reconstructions in 33 patients. The demographics between the prepectoral and subpectoral groups were similar in terms of age (52.4 ± 8.6 years vs 52.5 ± 12.1 years; p>0.05), smoking history (15.1 vs 13.6 percent; p>0.05), radiation history (75.8 vs 91.0 percent; p>0.05), and length of follow up (479 ± 326 vs 680 ± 494 days; p>0.05). The body mass index, however, was found to be significantly higher in the prepectoral group (27.6 ± 4.3 vs 25.2 ± 3.2 kg/m2; p<0.05) (Table 1). Total tissue expander fill volume was similar between the prepectoral and subpectoral groups (p>0.05; 518.2 ± 138.4 ml vs 482.3 ± 130.5 ml). Likewise, there was no statistically significant difference in terms of the mean implant sizes (p>0.05; 482.5 ±124.2 ml vs 470.5 ± 114.7 ml). Length of hospital stay was similar between the prepectoral and subpectoral groups (p>0.05; 2.2 ± 0.6 days vs 2.4 ± 0.5 days). Complications were observed at a similar rate between the two groups (Table 2). Three patients (9.1 percent) developed donor site hematoma in the prepectoral group as compared to none in the subpectoral group, with no statistically significant difference. There was no evidence of difference in terms of thromboembolic events; one patient (3.0 percent) developed deep vein thrombosis in the prepectoral group while a non-fatal incidence of pulmonary embolism was noted in one patient (4.5 percent) in the subpectoral group. Infections requiring reoperation which finally lead to a failure of reconstruction with removal of the tissue expander occurred in three patients (9.1 percent) in the prepectoral group and in one patient (4.5 percent) in the subpectoral
6
Prepectoral vs Subpectoral
group. This difference was not statistically significant. In both groups, seromas of the reconstructed breast were found in 6 patients (18.2 vs 27.3 percent), managed by needle drainage around the expander port. There were no cases of implant exposure in either group. Most common complication was donor site seroma in this series, noted in 66.7 percent of patients in the prepectoral and 40.9 percent in the subpectoral group, with no statistically significant difference. Animation deformity with Latissimus muscle twitching was observed at a similar rate between the groups, noted in 13 patients (39.4 percent) in the prepectoral groups as opposed to 11 patients (50.0 percent) in the subpectoral groups with no statistically significant difference. Revision rate between the groups was similar as well; 8 patients in the prepectoral group (24.2 percent) and 5 patients in the subpectoral group (22.8 percent) underwent autologous fat grafting to correct contour irregularities without any statistically significant difference. When asked to informally evaluate the aesthetic outcome at follow up (5= excellent, 4= good, 3= fair, 2= mediocre, 1= poor), patient satisfaction scores were similar between the two groups (4.33 ± 1.08 vs 4.14 ± 1.13, p= 0.52), with no statistically significant difference (Table 3). DISCUSSION Latissimus dorsi flap breast reconstruction can be accomplished satisfactorily in one stage implant placement.19-22 Since majority of the patients in this series had prior radiation treatment associated with breast conservation therapy, presenting for salvage mastectomy with reconstruction, we elected to employ a two-stage prosthetic reconstruction with the latissimus flap. This is based on previous published work,6,10-18 particularly related to similar clinical scenario of prior radiation treatment,6,11,18
7
Prepectoral vs Subpectoral
suggesting improved outcomes with two-stage expander/implant reconstruction with latissimus flap compared to a single stage procedure. Hammond14 and others6,11,16 emphasized that there is inevitable tissue swelling from the latissimus myocutaneous flap and therefore it is a difficult task to predict how much of this swelling will recede in order to determine the correct size of the implant in a one stage procedure. Moreover, swelling can also cause inordinate pressure on the mastectomy flaps given that an implant large enough to provide the desired volume is placed primarily, resulting in potential ischemia and possible necrosis of the mastectomy skin flap.14 Others13 raised the concern related to muscle atrophy that may develop months after the flap procedure, resulting in a smaller breast than initially designed for. Such difficulties can be eliminated by placing a tissue expander instead of an implant.
6,10-18
Even if the
device simply functions as a spacer, it allows the soft tissues to settle around it such that the contours of the breast can be assessed and manipulated as needed to provide the optimal result.14 Freeman et al.11 and Losken et al.16 stated that the presence of a tissue expander may be beneficial to oppose some of the contractile forces present early in the healing process, resulting in a softer capsule. Others14,16 reported that capsular contracture rates are lower and cosmetic results are more predictable with the two-staged procedure with latissimus flap. The authors14,16 reasoned that patients essentially undergo a capsulotomy at the time of exchange procedure which may be beneficial particularly in the setting of breast irradiation, along with other procedures of fine tuning that allows for creation of a breast with greater ptosis and more natural contours. Therefore, a two-stage prosthetic reconstruction was generally recommended
8
Prepectoral vs Subpectoral
with latissimus flap, with more consistent and generally more favorable results compared to primary implant placement.6, 10-18 Our experience, as well as previous work,10,11 proved that careful dissection of the latissimus muscle along its anatomic borders, to the level of thoracolumbar fascia caudally along with division of majority of its insertion allows for a large surface area of the muscle and unrestricted transposition to the chest, allowing complete coverage of a prosthetic device in its prepectoral position. In immediate breast reconstruction, this then begs the question whether pectoralis major muscle elevation is necessary since the prosthetic device can easily be covered completely by the latissimus flap. The ideal location for prosthetic devices in implant-only breast reconstruction has recently become a topic of discussion.12-16 Although several studies have been published comparing the subpectoral and prepectoral
placement in implant-only
prosthetic reconstruction, typically with the use of acellular dermal matrix products,13,14 to the best of our knowledge, our study is the first to report head to head comparison of the two approaches in two-stage prosthetic reconstruction with latissimus flap. In our study, we found that the rate of major complications were similar between the two groups. Most common complication was donor site seroma; although it was noted at a higher rate in the prepectoral group compared to the sub pectoral group, the difference was not statistically significant. Generally, donor site fluid collection following latissimus flap harvesting is not uncommon, ranging from 6 to 80 percent.17-21 The incidence appears to correlate with age, body mass index, flap size, and presence of concomitant lymphadenectomy.22,23 Our prepectoral cohort did have a significantly higher body mass index than the subpectoral cohort, which could be a factor for the
9
Prepectoral vs Subpectoral
reported difference. Several measures have been advocated in an attempt to mitigate this risk, such as quilting and progressive tension sutures and fibrin sealants. 24-26 Although prepectoral implant-only breast reconstruction is gaining popularity, showing promising data in cases with post mastectomy radiation following prepectoral acellular
dermal
matrix
coverage,27
literature
shows
evidence
of
increased
complications
in patients with prior history of radiation using implant-based breast
reconstruction,
2-5
including clinical experience with the prepectoral acellular dermal
matrix-only coverage.28 In fact, Gabriel and Maxwell 28 reported that they would not offer the prepectoral approach to those patients who have had radiation, given the increased risk of complications, unless the latissimus flap would also be utilized. Based on this study,
the
prepectoral approach for
prosthetic breast
reconstruction with latissimus flap is as safe and effective as the subpectoral technique. With similar complication rates and patient satisfaction, it does offer the advantage of avoiding pectoralis major muscle dissection. Furthermore, the subpectoral pocket is reserved for future site change should it become necessary such as in case of development of capsular contracture. Moreover, the prepectoral approach allows the breast borders to be precisely defined by suturing the muscle to the chest wall where it is considered aesthetically ideal, without being limited by the pectoralis muscle origin. We realize that this study has some limitations; both series were historical ones. The selection process between the two groups was inevitably time driven rather than random, namely, an evolution in practice from subpectoral to prepectoral. Therefore, there may be an uncontrollable variable of improvement in technique on the part of the surgeon although we did not modify any technical aspect over time. Finally, the number
10
Prepectoral vs Subpectoral
of patients studied were limited and as such higher number of cases in each group would increase the power of statistical analysis and conclusions drawn.
Conflict of interest statement The authors have no conflict of interest or funding. The institutional review board of our academic center approved this study. REFERENCES 1.
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2.
Nelson JA, Disa JJ. Breast reconstruction and radiation therapy: An update. Plast Reconstr Surg 2017; 140: 60S-68S.
3.
Lee KT, Mun GH. Prosthetic breast reconstruction in previously irradiated breasts: a meta analysis. J Surg Oncol 2015; 112: 468-475.
4.
Chen TA, Momeni A, Lee GK. Clinical outcomes in breast cancer expanderimplant reconstructive patients with radiation therapy. J Plast Reconstr Aesthet Surg 2016; 69: 14-22.
5.
Kearney AM, Brown MS, Soltanian HT. Timing of radiation and outcomes in implant based breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68: 1719-1726.
6.
Disa JJ, McCarthy CM, Mehrara BJ, et al. Immediate latissimus dorsi/prosthetic breast
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lumpectomy/radiation. Plast Reconstr Surg 2008; 121: 159e-164e.
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7.
Fisher JP, basta MN, Shubinets V, et al. A systematic meta analysis of prosthetic based breast reconstruction in irradiated fields
with or without autologous
muscle flap coverage. Ann Plast Surg 2016; 77: 129-134. 8.
Warren, A.G., et al., Breast reconstruction in a changing breast cancer treatment paradigm. Plast. Reconstr. Surg. 2008; 121: 1116-26.
9.
Schneider WJ, Hill HL, Brown RG. Latissimus doors myocutaneous flap for breast reconstruction. Br. J. Plast. Surg. 1977; 30: 277-281.
10.
Sternberg E, Perdikis G, McLaughlin S, Terkonda S, Waldorf J. Latissimus dorsi flap remains an excellent choice for breast reconstruction. Ann. Plast. Surg. 2006; 56: 31-35.
11.
Freeman M, Perdikis G, Sternberg E, Terkonda S, Waldorf J. Latissimus dorsi reconstruction: a good option for patients with failed breast conservation therapy. Ann. Plast. Surg. 2006; 57: 134-137.
12.
Elliott F, Ghazi B, Otterburn D. The scarless latissimus dorsi flap for full muscle coverage in device-based immediate breast reconstruction: An autologous alternative to acellular dermal matrix. Plast. Reconstr. Surg. 2011; 128: 71-79.
13.
Feng J, Pardoe C, Mota AM, Chui CHK, Tan BK. Two-stage latissimus dorsi flap with implant for unilateral breast reconstruction: getting the size right. Arch. Plast. Surg. 2016; 43; 197-203.
14.
Hammond DC. Latissimus dorsi flap breast reconstruction. Plast. Reconstr. Surg. 2009; 124: 1055-1063.
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15.
Pacella, S.J., et al., Aesthetic and technical refinements in latissimus dorsi implant breast reconstruction: a 15-year experience. Aesth. Surg. J. 2011; 31: 190-9.
16.
Losken A, Nicholas C, Pinell X, Carlson G. Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps. Ann. Plast. Surg. 2010; 65: 17-22.
17.
Yezhelyev M, Duggal C, Carlson G, Losken A. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann. Plast. Surg. 2013; 70: 557-562.
18.
Spear S, Boehmler J, Taylor N, Prada C. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Plast. Reconstr. Surg. 2007; 119: 1-9.
19.
DeLong M, Tandon V, Rudkin G, Da Lio A. Latissimus dorsi flap breast reconstruction-a nationwide inpatient sample review. Ann. Plast. Surg. 2017; 78: S185-S188.
20.
Chang D, Barnea Y, Robb G. Effects of an autologous flap combined with an implant
for
breast
reconstruction:
An
evaluation
of
1000
consecutive
reconstructions of previously irradiated breasts. Plast. Reconstr. Surg. 2008; 122: 356-362. 21.
Munhoz AM, Aldrighi C, Montag E, Arruda EG, Aldrighi JM, Filassi JR, Ferreria MC. Periareolar skin sparing mastectomy and latissimus dorsi flap with biodimensional expander implant reconstruction: surgical planning, outcomes, and complications. Plast. Reconstr. Surg. 2007: 119: 1637-1649.
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Prepectoral vs Subpectoral
22.
Smith BK, Cohen BE, Biggs TM, Suber J. Simultaneous bilateral breast reconstruction using latissimus dorsi myocutaneous flaps: A retrospective review of an institutional experience. Plast. Reconstr. Surg. 2011; 108: 1174-1181.
23.
Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant based breast reconstruction: rationale, indications and preliminary results. Plast Reconstr Surg 2017; 139: 287-294.
24.
Nahabedian MY, Cocilovo C. Two-stage prosthetic breast reconstruction: A comparison between prepectoral and partial subpectoral techniques. Plast Reconstr Surg 2017; 140: 22S-30S.
25.
Walia GS, Aston J, Bello R, et al. Prepectoral versus subpectoral tissue expander placement: A clinical and quality of life outcomes study. Plast Reconstr Surg Glob Open 2018; 6: e1731.
26.
Payday KZ, Wirth GA, Mowlds DS. Prepectoral breast reconstruction with fenestrated acellular dermal matrix: A novel design. Plast Reconstr Surg Glob Open 2018; 6: e1712.
27.
Wazir U, Mokbel K. The evolving role od prepectoral ADM-assisted implantbased immediate breast reconstruction following skin-sparing mastectomy. Am J Surg 2018, https://doi.org/10.1016/j.amjsurg.2018.01.021
28.
Schwabegger, A., et al., Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg, 1997; 38: 594-7.
29.
Delay, E., et al., Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. Plast Reconstr Surg, 1998; 102: 1461-78.
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30.
Roy, M.K., et al., Complications of latissimus dorsi myocutaneous flap breast reconstruction. Eur J Surg Oncol, 1998; 24: 162-5.
31.
Menke, H., M. Erkens, and R.R. Olbrisch, Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg, 2001; 47: 107-14.
32.
Clough, K.B., et al., Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg, 2002; 109: 1904-11.
33.
Randolph, L.C., et al., Prediction of postoperative seroma after latissimus dorsi breast reconstruction. Plast Reconstr Surg, 2005; 116: 1287-90.
34.
Jeon, B.J., et al., Risk factors for donor-site seroma formation after immediate breast reconstruction with the extended latissimus dorsi flap: a statistical analysis of 120 consecutive cases. Ann Plast Surg, 2012; 69: 145-7.
35.
Daltrey, I., et al., Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation. Br J Surg, 2006; 93: 825-30.
36.
Rios, J.L., T. Pollock, and W.P. Adams, Jr., Progressive tension sutures to prevent seroma formation after latissimus dorsi harvest. Plast Reconstr Surg, 2003; 112: 1779-83.
37.
Titley, O.G., G.E. Spyrou, and M.F. Fatah, Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg, 1997; 50: 106-8.
38.
Sbitany H, Gomez-Sanchez C, Piper M, Lentz R. Prepectoral breast reconstruction in the setting of postmastectomy radiation therapy: An assessment of clinical outcomes and benefits. Plast Reconstr Surg. 2019; 143: 10-20.
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Prepectoral vs Subpectoral
39.
Gabriel A, Maxwell P. Prepectoral breast reconstruction in challenging cases. Plast Reconstr Surg. 2017; 140: 14S-21S.
LEGENDS FOR FIGURES
Figure 1. Intraoperative view of the complete coverage of the implant by the latissimus muscle with prepectoral technique.
16
Prepectoral vs Subpectoral
Figure 2. A 62-year-old patient with previous history of failed bilateral breast conserving therapy presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at 3 years after exchange of 550 cc tissue expanders with 550 cc and 450 cc moderate plus profile smooth round gel implants, respectively, and bilateral nipple reconstruction.
17
Prepectoral vs Subpectoral
Figure 3. A 42-year-old patient with recurrent right breast cancer following lumpectomy and radiation presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at 2 years. Patient has 550 cc moderate plus profile smooth round gel implants after exchange with 550 cc tissue expanders.
18
Prepectoral vs Subpectoral
19
Prepectoral vs Subpectoral
Figure 4. A 45-year-old patient with left invasive ductal carcinoma presented for bilateral mastectomy and reconstruction with the prepectoral technique. A. Preoperative view. B. Postoperative view at one year after exchange of bilateral breast tissue expanders (550 cc) with permanent gel implants (500 cc moderate plus profile smooth surface round) as well as bilateral nipple reconstruction.
20
Prepectoral vs Subpectoral
Figure 5. A 63-year-old patient presented with recurrent right breast cancer. Patient had history of bilateral lumpectomy for cancer, axillary node dissection, and radiation treatment 7 and 14 years previously, respectively. Bilateral skin sparing mastectomy was performed with two-stage subpectoral prosthetic breast reconstruction using latissimus flap. A. Preoperative view. B. Postoperative view at 3 years after exchange of 550 cc medium height tissue expanders with 550 cc moderate plus profile smooth surface gel implant bilaterally.
Characteristic Number of patients
21
Prepectoral
Subpectoral
P value
33
22
NA
Prepectoral vs Subpectoral
Number of reconstructed breasts
50
36
NA
Age (years; mean ± SD)
52.4 ± 8.6
52.5 ± 12.1
0.97
Body mass index (kg/m2; mean ± SD)
27.6 ± 4.3
25.2 ± 3.2
0.03*
Smoking history (%)
5 (15.1)
3 (13.6)
1.00
Radiation history (%)
25 (75.7)
20 (90.9)
0.28
Length of follow up (days; mean ± SD)
479 ± 326
680 ± 494
0.07
Length of hospital stay (days; mean ± SD)
2.2 ± 0.6
2.4 ± 0.5
0.20
Table 1. Patient characteristics. SD denotes standard deviation. NA indicates non applicable. Statistically significant results are shown with * label.
Complication
Prepectoral (%) Subpectoral (%)
P value
Hematoma
3 (9.1)
0 (0.0)
0.26
Infection resulting in implant failure
3 (9.1)
1 (4.5)
0.64
Thromboembolic events
1 (3.0)
1 (4.5)
1.00
Donor site seroma
22 (66.7)
9 (40.9)
0.09
Breast seroma
6 (18.2)
6 (27.3)
0.51
Capsular Contracture
3 (9.1)
1 (4.5)
0.64
22
Prepectoral vs Subpectoral
Animation Deformity
13 (39.4)
11 (50.0)
0.58
Reoperation with fat grafting
8 (24.2)
5 (22.8)
1.00
Table 2. Complications.
Patient Satisfaction Score
Prepectoral (%)
Subpectoral (%)
5 (excellent)
21 (63.6)
12 (54.6)
4 (good)
6
(18.2)
4
(18.2)
3 (fair)
3
(9.1)
3
(13.6)
2 (mediocre)
2
(6.1)
3
(13.6)
1 (poor)
1
(3.0)
0
(0.0)
Mean ± SD
4.33 ± 1.08
4.14 ± 1.13
Table 3. Patient satisfaction. SD denotes standard deviation. There was no statistically significant difference between the groups (p= 0.52)
23
Prepectoral vs Subpectoral