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Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes

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Abstract

Purpose

 This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy.

Methods

Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS.

Results

In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups.

Conclusions

Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.

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References

  1. Albornoz CR, Bach PB, Mehrara BJ, Disa JJ, Pusic AL, McCarthy CM, Cordeiro PG, Matros E (2013) A paradigm shift in US breast reconstruction: increasing implant rates. Plast Reconstr Surg 131(1):15–23

    Article  CAS  PubMed  Google Scholar 

  2. Manrique OJ, Banuelos J, Abu-Ghname A, Nguyen MD, Tran NV, Martinez-Jorge J, Harless C, Sharaf B, Jakub JW, Degnim AC et al (2019) Surgical outcomes of prepectoral versus subpectoral ibbr in young women. Plast Reconstr Surg Glob Open 7(3):e2119

    Article  PubMed  PubMed Central  Google Scholar 

  3. Manrique OJ, Kapoor T, Banuelos J, Jacobson SR, Martinez-Jorge J, Nguyen MT, Tran NV, Harless CA, Degnim AC, Jakub JW (2019) Single-stage direct-to-implant breast reconstruction: a comparison between subpectoral versus prepectoral implant placement. Ann Plast Surg. https://doi.org/10.1097/01.GOX.0000558354.18596.c6

    Article  PubMed  Google Scholar 

  4. Sigalove S, Maxwell GP, Sigalove NM, Storm-Dickerson TL, Pope N, Rice J, Gabriel A (2017) Prepectoral IBBR and postmastectomy radiotherapy: short-term outcomes. Plast Reconstr Surg Glob Open 5(12):e1631

    Article  PubMed  PubMed Central  Google Scholar 

  5. Becker H, Lind JG 2nd, Hopkins EG (2015) Immediate implant-based prepectoral breast reconstruction using a vertical incision. Plast Reconstr Surg Glob Open 3(6):e412

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bettinger LN, Waters LM, Reese SW, Kutner SE, Jacobs DI (2017) Comparative study of prepectoral and subpectoral expander-based breast reconstruction and Clavien IIIb Score outcomes. Plast Reconstr Surg Glob Open 5(7):e1433

    Article  PubMed  PubMed Central  Google Scholar 

  7. Woo A, Harless C, Jacobson SR (2017) Revisiting an old place: single-surgeon experience on post-mastectomy subcutaneous IBBR. Breast J 23(5):545–553

    Article  PubMed  Google Scholar 

  8. Casella D, Di Taranto G, Marcasciano M, Sordi S, Kothari A, Kovacs T, Lo Torto F, Cigna E, Calabrese C, Ribuffo D (2019) Evaluation of prepectoral implant placement and complete coverage with TiLoop bra mesh for breast reconstruction: a prospective study on long-term and patient-reported BREAST-Q outcomes. Plast Reconstr Surg 143(1):1e–9e

    Article  CAS  PubMed  Google Scholar 

  9. Salibian AA, Frey JD, Choi M, Karp NS (2016) Subcutaneous IBBR with acellular dermal matrix/mesh: a systematic review. Plast Reconstr Surg Glob Open 4(11):e1139

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jones G, Yoo A, King V, Jao B, Wang H, Rammos C, Elwood E (2017) Prepectoral immediate direct-to-implant breast reconstruction with anterior alloderm coverage. Plast Reconstr Surg 140(6S):31S–38S

    Article  CAS  PubMed  Google Scholar 

  11. Reitsamer R, Peintinger F, Klaassen-Federspiel F, Sir A (2019) Prepectoral direct-to-implant breast reconstruction with complete ADM or synthetic mesh coverage–36-months follow-up in 200 reconstructed breasts. Breast 48:32–37

    Article  PubMed  Google Scholar 

  12. Tousimis E, Haslinger M (2018) Overview of indications for nipple sparing mastectomy. Gland Surg 7(3):288–300

    Article  PubMed  PubMed Central  Google Scholar 

  13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–e34

    Article  PubMed  Google Scholar 

  14. Higgins JP, Green S (2011) Cochrane handbook for systematic reviews of interventions, vol 4. Wiley, Hoboken

    Google Scholar 

  15. Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14(135):1–13

    Google Scholar 

  16. Nealon KP, Weitzman RE, Sobti N, Jimenez RB, Ehrlichman R, Faulkner HR, Gadd M, Specht M, Austen WG, Liao EC (2020) Prepectoral direct-to-implant breast reconstruction: safety outcome endpoints and delineation of risk factors. Plast Reconstr Surg 145:898e–908e

    Article  CAS  PubMed  Google Scholar 

  17. Sinnott CJ, Persing SM, Pronovost M, Hodyl C, McConnell D, Ott Young A (2018) Impact of postmastectomy radiation therapy in prepectoral versus subpectoral IBBR. Ann Surg Oncol 25(10):2899–2908

    Article  PubMed  Google Scholar 

  18. Chandarana MN, Jafferbhoy S, Marla S, Soumian S, Narayanan S (2018) Acellular dermal matrix in implant-based immediate breast reconstructions: a comparison of prepectoral and subpectoral approach. Gland Surg 7(Suppl 1):S64–S69

    Article  PubMed  PubMed Central  Google Scholar 

  19. Tasoulis M-K, Iqbal F, Cawthorn S, MacNeill F, Vidya R (2017) Subcutaneous implant breast reconstruction: time to reconsider? Eur J Surg Oncol 43(9):1636–1646

    Article  PubMed  Google Scholar 

  20. Rebowe RE, Allred LJ, Nahabedian MY (2018) The evolution from subcutaneous to prepectoral prosthetic breast reconstruction. Plast Reconstr Surg Glob Open 6(6):e1797

    Article  PubMed  PubMed Central  Google Scholar 

  21. Chun YS, Verma K, Rosen H, Lipsitz S, Morris D, Kenney P, Eriksson E (2010) IBBR using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg 125(2):429–436

    Article  CAS  PubMed  Google Scholar 

  22. Breuing KH, Colwell AS (2007) Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg 59(3):250–255

    Article  CAS  PubMed  Google Scholar 

  23. Spear SL, Sher SR, Al-Attar A, Pittman T (2014) Applications of acellular dermal matrix in revision breast reconstruction surgery. Plast Reconstr Surg 133(1):1–10

    Article  CAS  PubMed  Google Scholar 

  24. Ter Louw RP, Nahabedian MY (2017) Prepectoral breast reconstruction. Plast Reconstr Surg 140(5S):51S–59S

    Article  PubMed  CAS  Google Scholar 

  25. Nahabedian M, Spear S (2011) Acellular dermal matrix for secondary procedures following prosthetic breast reconstruction. Aesthet Surg J 31(7Supplement):38S–50S

    Article  PubMed  Google Scholar 

  26. Li L, Su Y, Xiu B, Huang X, Chi W, Hou J, Zhang Y, Tian J, Wang J, Wu J (2019) Comparison of prepectoral and subpectoral breast reconstruction after mastectomies: a systematic review and meta analysis. Eur J Surg Oncol. https://doi.org/10.1016/j.ejso.2019.05.015

    Article  PubMed  Google Scholar 

  27. Lentz R, Alcon A, Sbitany H (2019) Correction of animation deformity with subpectoral to prepectoral implant exchange. Gland Surg 8(1):75–81

    Article  PubMed  PubMed Central  Google Scholar 

  28. Wormer BA, Valmadrid AC, Ganesh Kumar N, Al Kassis S, Rankin TM, Kaoutzanis C, Higdon KK (2019) Reducing expansion visits in immediate IBBR: a comparative study of prepectoral and subpectoral expander placement. Plast Reconstr Surg 144(2):276–286

    Article  CAS  PubMed  Google Scholar 

  29. Kaplan J, Wagner RD, Braun TL, Chu C, Winocour SJ (2019) Prepectoral breast reconstruction. Seminars in plastic surgery. Thieme Medical Publishers, New York, pp 236–239

    Google Scholar 

  30. Nahabedian MY, Cocilovo C (2017) Two-stage prosthetic breast reconstruction: a comparison between prepectoral and partial subpectoral techniques. Plast Reconstr Surg 140(6S):22S–30S

    Article  CAS  PubMed  Google Scholar 

  31. Kim SE (2019) Prepectoral breast reconstruction. Yeungnam Univ J Med 26(3):201–207

    Article  Google Scholar 

  32. Harless CA, Jacobson SR (2016) Tailoring through technology: a retrospective review of a single surgeon's experience with implant-based breast reconstruction before and after implementation of laser-assisted indocyanine green angiography. Breast J 22(3):274–281

    Article  CAS  PubMed  Google Scholar 

  33. Newman MI, Samson MC, Tamburrino JF et al (2010) Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg 26:487–492

    Article  PubMed  Google Scholar 

  34. Sorkin M, Qi J, Kim HM, Hamill JB, Kozlow JH, Pusic AL, Wilkins EG (2017) Acellular dermal matrix in immediate expander/implant breast reconstruction: a multicenter assessment of risks and benefits. Plast Reconstr Surg 140(6):1091–1100

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Sbitany H, Piper M, Lentz R (2017) Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy. Plast Reconstr Surg 140(3):432–443

    Article  CAS  PubMed  Google Scholar 

  36. Chatterjee A, Nahabedian MY, Gabriel A, Macarios D, Parekh M, Wang F, Griffin L, Sigalove S (2018) Early assessment of post-surgical outcomes with pre-pectoral breast reconstruction: a literature review and meta-analysis. J Surg Oncol 117(6):1119–1130

    Article  PubMed  Google Scholar 

  37. Copeland-Halperin LR, Yemc L, Emery E, Collins D, Liu C, Mesbahi AN, Venturi ML (2019) Evaluating postoperative narcotic use in prepectoral versus dual-plane breast reconstruction following mastectomy. Plast Reconstr Surg Glob Open 7(2):e2082

    Article  PubMed  PubMed Central  Google Scholar 

  38. Pandey S, Chittoria RK, Mohapatra DP, Friji M, Sivakumar DK (2017) Mnemonics for gillies principles of plastic surgery and it importance in residency training programme. Indian J Plast Surg 50(01):114–115

    Article  PubMed  PubMed Central  Google Scholar 

  39. Schnarrs RH, Carman CM, Tobin C, Chase SA, Rossmeier KA (2016) Complication rates with human acellular dermal matrices: retrospective review of 211 consecutive breast reconstructions. Plast Reconstr Surg Glob Open 4(11):e1118

    Article  PubMed  PubMed Central  Google Scholar 

  40. Banuelos J, Abu-Ghname A, Vyas K, Sharaf B, Nguyen MT, Harless C, Manrique OJ, Martinez-Jorge J, Tran NV (2019) Should obesity be considered a contraindication for prepectoral breast reconstruction? Plast Reconstr Surg 145:619–627

    Article  CAS  Google Scholar 

  41. Zhu L, Mohan AT, Abdelsattar JM, Wang Z, Vijayasekaran A, Hwang SM, Tran NV, Saint-Cyr M (2016) Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction. J Plast Reconstr Aesthet Surg 69(4):e77–86

    Article  PubMed  Google Scholar 

  42. Mirhaidari SJ, Azouz V, Wagner DS (2019) Prepectoral versus subpectoral direct to implant immediate breast reconstruction. Ann Plast Surg 84:263–270

    Article  CAS  Google Scholar 

  43. Holzgreve W, Beller FK (1987) Surgical complications and follow-up evaluation of 163 patients with subcutaneous mastectomy. Aesthetic Plast Surg 11(1):45–48

    Article  CAS  PubMed  Google Scholar 

  44. Nahabedian MY (2012) Acellular dermal matrices in primary breast reconstruction: principles, concepts, and indications. Plast Reconstr Surg 130(5S-2):44S–53S

    Article  CAS  PubMed  Google Scholar 

  45. Schmitz M, Bertram M, Kneser U, Keller AK, Horch RE (2013) Experimental total wrapping of breast implants with acellular dermal matrix: a preventive tool against capsular contracture in breast surgery? J Plast Reconstr Aesthet Surg 66(10):1382–1389

    Article  PubMed  Google Scholar 

  46. Sobti N, Weitzman R, Nealon K, Jimenez R, Gfrerer L, Mattos D, Liao E (2020) Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct-to-implant breast reconstruction. Sci Rep 10(1):1137

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Nahabedian MY (2018) Current approaches to prepectoral breast reconstruction. Plast Reconstr Surg 142(4):871–880

    Article  CAS  PubMed  Google Scholar 

  48. Gabriel A, Sigalove S, Sigalove NM, Storm-Dickerson TL, Rice J, Pope N, Maxwell GP (2018) Prepectoral revision breast reconstruction for treatment of implant-associated animation deformity: a review of 102 reconstructions. Aesthet Surg J 38(5):519–526

    Article  PubMed  Google Scholar 

  49. Hammond DC, Schmitt WP, O’Connor EA (2015) Treatment of breast animation deformity in implant-based reconstruction with pocket change to the subcutaneous position. Plast Reconstr Surg 135(6):1540–1544

    Article  CAS  PubMed  Google Scholar 

  50. Holland MC, Lentz R, Sbitany H (2019) Surgical correction of breast animation deformity with implant pocket conversion to a prepectoral plane. Plast Reconstr Surg 145:632–642

    Article  CAS  Google Scholar 

  51. Kobraei EM, Cauley R, Gadd M, Austen WG Jr, Liao EC (2016) Avoiding breast animation deformity with pectoralis-sparing subcutaneous direct-to-implant breast reconstruction. Plast Reconstr Surg Glob Open 4(5):e708

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kim JY, Qiu CS, Chiu W-K, Feld LN, Mioton LM, Kearney A, Fracol M (2019) A quantitative analysis of animation deformity in prosthetic breast reconstruction. Plast Reconstr Surg 144(2):291–301

    Article  CAS  PubMed  Google Scholar 

  53. Sigalove S, Maxwell GP, Sigalove NM, Storm-Dickerson TL, Pope N, Rice J, Gabriel A (2017) Prepectoral IBBR: rationale, indications, and preliminary results. Plast Reconstr Surg 139(2):287–294

    Article  CAS  PubMed  Google Scholar 

  54. Keehn A, Olson D, Dort J, Parker S, Anderes S, Headley L, Quan M (2019) Same-day surgery for mastectomy patients in Alberta: a perioperative care pathway and quality improvement initiative. Ann Surg Oncol 26(10):3354–3360

    Article  PubMed  Google Scholar 

  55. Case C, Johantgen M, Steiner C (2001) Outpatient mastectomy: clinical, payer, and geographic influences. Health Serv Res 36(5):869–86984

    CAS  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA

    Olivia Abbate, Nikki Rosado, Nikhil Sobti, Brittany L. Vieira & Eric C. Liao

  2. Harvard Medical School, 55 Fruit St Suite 435, Boston, MA, 02114, USA

    Eric C. Liao

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  1. Olivia Abbate
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  2. Nikki Rosado
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  3. Nikhil Sobti
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  4. Brittany L. Vieira
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Contributions

OA Author made substantial contributions to the acquisition of data, interpretation of data, drafting of the work, substantively revised draft of work, approved the submitted version and agreed to be both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. NR Author made substantial contributions to the acquisition of data, interpretation of data, drafting of the work, substantively revised draft of work, approved the submitted version and agreed to be both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. NS Author made substantial contributions to the acquisition of data, interpretation of data, drafting of the work, substantively revised draft of work, approved the submitted version and agreed to be both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. BLV Author made substantial contributions to the conception and design of the work, substantively revised draft of work, approved the submitted version and agreed to be both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. ECL Author made substantial contributions to the conception and design of the work, interpretation of data, substantively revised draft of work, approved the submitted version and agreed to be both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work.

Corresponding author

Correspondence to Eric C. Liao.

Ethics declarations

Conflict of interest

Eric C. Liao has consultant agreements with, but is explicitly not a speaker for, Musculoskeletal Transplant Foundation and Allergan Inc., manufacturers of FlexHD and AlloDerm, respectively. Other authors declare that they have no conflict to interest.

Ethical approval

This study is a meta-analysis, with secondary analysis of published data. No human interaction was involved and no IRB review was needed.

Informed consent

This study is a meta-analysis, with secondary analysis of published data. No human interaction was involved and no informed consent was needed.

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Electronic supplementary material

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10549_2020_5722_MOESM1_ESM.tiff

Supplementary file1 (TIFF 86221 kb)—Supplemental Figure 1. Individual forest plots for primary post-operative endpoints.

10549_2020_5722_MOESM2_ESM.tiff

Supplementary file2 (TIFF 5439 kb)—Supplemental Figure 2. Funnel plots for primary post-operative endpoints of seroma,hematoma, and wound dehiscence, which demonstrate no publication bias across includedstudies.

10549_2020_5722_MOESM3_ESM.tif

Supplementary file3 (TIF 56811 kb)—Supplemental Figure 3. Sensitivity analysis for primary post-operative endpoints of interest,which revealed no significant change in outcome with stepwise elimination of included studies.

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Abbate, O., Rosado, N., Sobti, N. et al. Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes. Breast Cancer Res Treat 182, 543–554 (2020). https://doi.org/10.1007/s10549-020-05722-2

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  • DOI: https://doi.org/10.1007/s10549-020-05722-2

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