Journal time! This was out of the Aesthetic Surgery Journal November 2023, “Comparison of Complication Rates Between Subpectoral vs. Prepectoral Techniques in Prosthetic Breast Reconstruction.” This is for breast reconstruction following cancer. As you may know, there has been a general trend in breast cancer reconstruction to put tissue expanders and breast implants in front of the pectoral muscle. They tend to wrap the implants in ADM or mesh but are putting it essentially directly under the skin after mastectomy.
But is this safe?
This was a retrospective cohort study to look at women who had 2 stage breast cancer reconstruction with tissue expander followed by breast implant. Early complications were defined as anything within 30 days after surgery. 854 patients were included. Findings?
BEHIND the muscle:
- 76% were under the pectoral muscle for tissue expander
- 34% early complication rate (Reason: reintervention, followed by flap necrosis) and 36% late complication rate after first stage (Reason: expander malposition, breast reconstruction failure).
- Second stage (placement of implant) had a 16.3% early (Reason; capsule revision); 16.1% late complication rate (Reason: failure of reconstruction, need for reintervention)
IN FRONT of the muscle:
- Tissue expanders placed in front of the muscle had higher hazard ratio for developing early and late infection after the first stage. (two times higher rate)
- Late complications in the tissue expander seen were failure of breast reconstruction, infection, and wound dehiscence.
- Higher infection hazard after the second stage of reconstruction
- They had significantly higher rates of failure of breast reconstruction, seromas (fluid collection) and infections. Time to developing complications was slightly shorter.
They conclude the overall rates were similar at about 20%, but infection rates are clearly higher in the prepectoral group.
In their discussion, they do state that they will only do prepectoral placement if the mastectomy flaps are thicker. This means higher risk patients with thin flaps are getting placement behind the muscle, so if these patients had placement in front of the muscle, the complication rates would be even higher.
My thoughts?
Prepectoral placement seems to be the trend. This study which had some conflicting data (it seemed to mention higher rates of failure, seromas, etc ) but then stated the overall complication rates were similar. They really thought the real differentiator in complications was infection.
The benefits to not placing below the muscle are lower rates of pain and no animation issues when you exercise.
They emphasize which I agree with that the choice really depends on the patient’s anatomy. If the skin is thin, you have to place the implant or tissue expander behind the muscle. If the mastectomy flaps are thicker, then in front of the muscle is compelling, as long as the patients understand that there is a higher risk of infection issues.