E. Theodorakopoulou1, D. T. Ghorra1,2, S. Samaras1, P. Forouhi3, C. M. Malata1,3,4 1Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 2University of Alexandria Medical School,Department Of Plastic & Reconstructive Surgery,Alexandria, ALEXANDRIA, Egypt 3Cambridge Breast Unit,Department Of Surgery,Cambridge, ENGLAND, United Kingdom 4Anglia Ruskin Univerisity School of Medicine,Surgery,Cambridge & Chelmsford, ENGLAND, United Kingdom
Introduction:
Epipectoral implant placement is a new technic designed to simplify and minimize the drawbacks of immediate implant-based breast reconstruction. As with most new procedures the indications have yet to be clearly defined. A single plastic surgeon's initial experience with prosthetic reconstruction using BraxonR total acellular dermal matrix coverage of the implant/expander in the prepectoral plane at the time of mastectomy is presented.
Methods:
Patients undergoing Braxon (porcine ADM) immediate breast reconstruction by a single surgeon (2017-2018) were reviewed with respect to demographics, specific indication, implant type & volume, mastectomy type and early outcomes. They were identified from a prospective Implant Register and data collected from Epic.
Results:
Eleven consecutive patients (mean age 38 years) underwent Braxon-ADM reconstruction of 17 breasts with fixed volume implants i.e., direct-to-implant (7) and permanent expanders (4). The surgical indications (number of breasts) were risk-reduction (9), therapeutic (6) and noncancer (2). The reconstructions were bilateral in six patients. Based on the breast size and shape, mastectomies were performed via a variety of incisions: Wise pattern skin-reducing technics (6 with half of them including dermal slings), inframammary incisions (4), hemi-Y periareolar incisions (4) and traditional elliptical periareolar incisions (3). Twelve breasts had nipple-sparing mastectomies. Uneventful healing was achieved in 9 breasts, implant loss 4 breasts, large seromas (5 breasts – 2 of the implant losses), infection (4 breasts, included in the implant losses), unplanned readmissions (3 patients), severe capsular contracture following unplanned radiotherapy (1 breast), transient localised tenderness at the superior fixation points (3 breasts), exercise-induced "partial dislodging" (1 breast) and visible rippling (4 breasts). Unlike subpectoral breast recosntructions there were no cases of breast animation deformity caused by hyperactive pectoralis major muscle contraction with resulting distortion of the breasts.
The putative prredisposing factors (by patients) to implant loss and significant seromas/ wound dehiscence were smoking (1), skin-reducing mastectomy (2), early (<5 days) removal of drains (1), tight wound closure (1), postoperative radiotherapy (1) and axillary clearance (1).
Conclusion:
Prepectoral implant placement constitutes a practical novel addition to the repertoire of postmastectomy breast reconstruction technics. It is particularly useful in bilateral reconstructions such as for risk-reducing mastectomies. Patient selection is, however, very important to avoid complications and optimise outcomes. It is also more exacting in terms of implant selection for unilateral breast reconstruction. Further large-scale studies are needed to determine the place of prepectoral reconstruction and whether it is an improvement on current implant-based reconstructive methods.