OpenLB
Open Library of Bioscience
Advanced Search
Plastic and reconstructive surgery
Jan 01, 2025;155 (1): 213e-227e.

Prepectoral Breast Reconstruction.

Akhil K Seth, Mark Sisco
Author Information
  1. Akhil K Seth: From the Division of Plastic and Reconstructive Surgery, Department of Surgery, NorthShore University HealthSystem.
  2. Mark Sisco: From the Division of Plastic and Reconstructive Surgery, Department of Surgery, NorthShore University HealthSystem.
PMID: 39700251 DOI: 10.1097/PRS.0000000000011737

Abstract

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe indications and patient factors relevant to performing prepectoral breast reconstruction. 2. Understand the effects of different types of implants and implant support in prepectoral breast reconstruction. 3. Describe techniques for surgical revision to improve outcomes in prepectoral breast reconstruction. 4. Understand the current literature surrounding clinical and quality-of-life outcomes in prepectoral breast reconstruction.
SUMMARY: This article goes beyond a general review of prepectoral breast reconstruction, providing a working framework and important considerations for any surgeon utilizing prepectoral breast reconstruction techniques. This article also addresses current controversies, provides practice tips and technical pearls, and addresses gaps in knowledge with both opinion and a review of the most current literature.

References

  1. Snyderman RK, Guthrie RH. Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg. 1971;47:565–567.
  2. Maxwell GP, Gabriel A. The evolution of breast implants. Clin Plast Surg. 2009;36:1–13, v.
  3. Kelly AP Jr, Jacobson HS, Fox JI, Jenny H. Complications of subcutaneous mastectomy and replacement by the Cronin Silastic mammary prosthesis. Plast Reconstr Surg. 1966;37:438–445.
  4. Rebowe RE, Allred LJ, Nahabedian MY. The evolution from subcutaneous to prepectoral breast reconstruction. Plast Reconstr Surg Glob Open 2018;6:e1797.
  5. Apfelberg DB, Laub DR, Maser MR, Lash H. Submuscular breast reconstruction: indications and techniques. Ann Plast Surg. 1981;7:213–221.
  6. Gruber RP, Kahn RA, Lash H, Maser MR, Apfelberg DB, Laub DR. Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg. 1981;67:312–317.
  7. Nahabedian MY. Acellular dermal matrices in primary breast reconstruction: principles, concepts, and indications. Plast Reconstr Surg. 2012;130(5 Suppl 2):44S–53S.
  8. Sbitany H, Serletti JM. Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity. Plast Reconstr Surg. 2011;128:1162–1169.
  9. Kim JYS, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129:28–41.
  10. Sbitany H, Sandeen SN, Amalfi AN, Davenport MS, Langstein HN. Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes. Plast Reconstr Surg. 2009;124:1735–1740.
  11. Cerceo JR, Cai L, Yesantharao P, Thornton B, Nazerali R. Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity. J Plast Reconstr Aesthet Surg. 2023;77:253–261.
  12. Lentz R, Alcon A, Sbitany H. Correction of animation deformity with subpectoral to prepectoral implant exchange. Gland Surg. 2019;8:75–81.
  13. Plachinski SJ, Boehm LM, Adamson KA, LoGiudice JA, Doren EL. Comparative analysis of prepectoral versus subpectoral implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2021;9:e3709.
  14. Escandón JM, Weiss A, Christiano JG, et al. Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review. Ann Transl Med. 2023;11:411.
  15. Antony AK, Poirier J, Madrigrano A, Kopkash KA, Robinson EC. Evolution of the surgical technique for “breast in a day” direct-to-implant breast reconstruction: transitioning from dual-plane to prepectoral implant placement. Plast Reconstr Surg. 2019;143:1547–1556.
  16. Rebowe RE, Allred LJ, Nahabedian MY. The evolution from subcutaneous to prepectoral prosthetic breast reconstruction. Plast Reconstr Surg Glob Open 2018;6:e1797.
  17. Nahabedian MY. Innovations and advancements with prosthetic breast reconstruction. Breast J. 2018;24:586–591.
  18. Graziano FD, Plotsker EL, Rubenstein RN, et al. National trends in acellular dermal matrix utilization in immediate breast reconstruction. Plast Reconstr Surg. 2024;153:25e–36e.
  19. Nahabedian MY, Cocilovo C. Two-stage prosthetic breast reconstruction: a comparison between prepectoral and partial subpectoral techniques. Plast Reconstr Surg. 2017;140:22S–30S.
  20. Jones G, Yoo A, King V, et al. Prepectoral immediate direct-to-implant breast reconstruction with anterior AlloDerm coverage. Plast Reconstr Surg. 2017;140:31S–38S.
  21. Onesti MG, Maruccia M, Di Taranto G, et al. Clinical, histological, and ultrasound follow-up of breast reconstruction with one-stage muscle-sparing “wrap” technique: a single-center experience. J Plast Reconstr Aesthet Surg. 2017;70:1527–1536.
  22. Khalil HH, Malahias MN, Youssif S, Ashour T, Rhobaye S, Faroq T. Nipple-sparing mastectomy and prepectoral implant/acellular dermal matrix wrap reconstruction in large ptotic breasts. Plast Reconstr Surg Glob Open 2019;7:e2289.
  23. Salibian AA, Karp NS. Modern approaches to implant-based breast reconstruction. Clin Plast Surg. 2023;50:223–234.
  24. Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple-sparing mastectomy. J Surg Oncol. 2020;122:29–35.
  25. Galimberti V, Vicini E, Corso G, et al. Nipple-sparing and skin-sparing mastectomy: review of aims, oncological safety and contraindications. Breast 2017;34:S82–S84.
  26. Murthy V, Chamberlain RS. Defining a place for nipple sparing mastectomy in modern breast care: an evidence based review. Breast J. 2013;19:571–581.
  27. von Fritschen U, Seidenstücker K, Sigalove S. Current trends in postmastectomy breast reconstruction. Curr Opin Obstet Gynecol. 2023;35:73–79.
  28. Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-based breast reconstruction after mastectomy, from the subpectoral to the prepectoral approach: an evidence-based change of mind? J Clin Med. 2022;11:3079.
  29. Vidya R, Masia J, Cawthorn S, et al. Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: first multicenter European report on 100 cases. Breast J. 2017;23:670–676.
  30. Kobraei EM, Cauley R, Gadd M, Austen WG Jr, Liao EC. Avoiding breast animation deformity with pectoralis-sparing subcutaneous direct-to-implant breast reconstruction. Plast Reconstr Surg Glob Open 2016;4:e708.
  31. Bernini M, Calabrese C, Cecconi L, et al. Subcutaneous direct-to-implant breast reconstruction: Surgical, functional, and aesthetic results after long-term follow-up. Plast Reconstr Surg Glob Open 2015;3:e574.
  32. Casella D, Calabrese C, Bianchi S, Meattini I, Bernini M. Subcutaneous tissue expander placement with synthetic titanium-coated mesh in breast reconstruction: Long-term results. Plast Reconstr Surg Glob Open 2015;3:e577.
  33. Reitsamer R, Peintinger F. Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: A new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg. 2015;68:162–167.
  34. Berna G, Cawthorn SJ, Papaccio G, Balestrieri N. Evaluation of a novel breast reconstruction technique using the Braxon acellular dermal matrix: A new muscle-sparing breast reconstruction. ANZ J Surg. 2017;87:493–498.
  35. Rubenstein RN, Kim M, Plotsker EL, et al. Early complications in prepectoral tissue expander-based breast reconstruction. Ann Surg Oncol. 2024;31:2766–2776.
  36. Kim YH, Yang YJ, Lee DW, Song SY, Lew DH, Yang EJ. Prevention of postoperative complications by prepectoral versus subpectoral breast reconstruction: A systematic review and meta-analysis. Plast Reconstr Surg. 2024;153:10e–24e.
  37. Houvenaeghel G, Cohen M, Sabiani L, et al. Mastectomy and immediate breast reconstruction with pre-pectoral or sub-pectoral implant: assessing clinical practice, post-surgical outcomes, patient’s satisfaction and cost. J Surg Res (Houst). 2022;5:500–510.
  38. Escandón JM, Sweitzer K, Christiano JG, et al. Subpectoral versus prepectoral two-stage breast reconstruction: a propensity score-matched analysis of 30-day morbidity and long-term outcomes. J Plast Reconstr Aesthet Surg. 2023;76:76–87.
  39. Nelson JA, Shamsunder MG, Vorstenbosch J, et al. Prepectoral and subpectoral tissue expander-based breast reconstruction: a propensity-matched analysis of 90-day clinical and health-related quality-of-life outcomes. Plast Reconstr Surg. 2022;149:607e–616e.
  40. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation. Plast Reconstr Surg. 2012;129:354–361.
  41. Sinnott CJ, Pronovost MT, Persing SM, Wu R, Young AO. The impact of premastectomy versus postmastectomy radiation therapy on outcomes in prepectoral implant-based breast reconstruction. Ann Plast Surg. 2021;87:S21–S27.
  42. Ostapenko E, Nixdorf L, Devyatko Y, Exner R, Wimmer K, Fitzal F. The impact of adjuvant radiotherapy on immediate prepectoral implant-based breast reconstruction. Aesthetic Plast Surg. 2023;48:2432–2438.
  43. Awadeen A, Fareed M, Elameen AM. The impact of postmastectomy radiation therapy on the outcomes of prepectoral implant-based breast reconstruction: a systematic review and meta-analysis. Aesthetic Plast Surg. 2023;47:81–91.
  44. Highton L, Johnson R, Kirwan C, Murphy J. Prepectoral implant-based breast reconstruction. Plast Reconstr Surg Glob Open 2017;5:e1488.
  45. Elswick SM, Harless CA, Bishop SN, et al. Prepectoral implant-based breast reconstruction with postmastectomy radiation therapy. Plast Reconstr Surg. 2018;142:1–12.
  46. Zheng C, Liu J, Wen Y, Lin S, Han H, Xu C. A systematic review and meta-analysis of postmastectomy radiation therapy on prepectoral versus subpectoral breast reconstruction. Front Surg. 2023;9:1019950.
  47. Piccolo PP, Venturi M, Mesbahi AN, Nahabedian MY. Current status prepectoral and subpectoral breast reconstruction in the USA. Gland Surg. 2023;12:1794–1805.
  48. van der Wielen A, Negenborn V, Burchell GL, Remmelzwaal S, Lapid O, Driessen C. Less is more? One-stage versus two-stage implant-based breast reconstruction: a systematic review and meta-analysis of comparative studies. J Plast Reconstr Aesthet Surg. 2023;86:109–127.
  49. Huang A, Kuchta K, Alva D, Sisco M, Seth AK. Wise-pattern mastectomy with an inferior dermal sling: a viable alternative to elliptical mastectomy in prosthetic based breast reconstruction. Plast Reconstr Surg. 2023;153:505e–515e.
  50. Domenici L, Caputo GG, Losco L, et al. Muscle-sparing skin-reducing breast reconstruction with pre-pectoral implants in breast cancer patients: long-term assessment of patients’ satisfaction and quality of life. J Invest Surg. 2022;35:841–847.
  51. Lee JS, Park E, Lee JH, et al. A prospective comparison study of early functional outcomes after implant-based breast reconstruction: subpectoral versus prepectoral technique. Ann Palliat Med. 2021;10:2520–2529.
  52. Caputo GG, Zingaretti N, Kiprianidis I, et al. Quality of life and early functional evaluation in direct-to-implant breast reconstruction after mastectomy: a comparative study between prepectoral versus dual-plane reconstruction. Clin Breast Cancer 2021;21:344–351.
  53. Krishnan NM, Fischer JP, Basta MN, Nahabedian MY. Is single-stage prosthetic reconstruction cost effective? A cost-utility analysis for the use of direct-to-implant breast reconstruction relative to expander-implant reconstruction in postmastectomy patients. Plast Reconstr Surg. 2016;138:537–547.
  54. Khavanin N, Yang JH, Colakoglu S, et al. Breast reconstruction trends in the setting of postmastectomy radiation therapy: analysis of practices among plastic surgeons in the United States. Plast Reconstr Surg Glob Open 2023;11:e4800.
  55. Sigalove S. Options in acellular dermal matrix: device assembly. Plast Reconstr Surg. 2017;140:39S–42S.
  56. Scarabosio A, Contessi Negrini F, Pisano G, et al. Prepectoral direct-to-implant one-stage reconstruction with ADMs: safety and outcome in “thin patients.” Clin Breast Cancer 2023;23:e507–e514.
  57. Samaha Y, Chen J, Ray EC. ADMs and synthetic meshes improve implant-based breast reconstruction aesthetics, but at what cost? J Plast Reconstr Aesthet Surg. 2023;80:178–181.
  58. Basu CB, Leong M, Hicks MJ. Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery. Plast Reconstr Surg. 2010;126:1842–1847.
  59. Leong M, Basu CB, Hicks MJ. Further evidence that human acellular dermal matrix decreases inflammatory markers of capsule formation in implant-based breast reconstruction. Aesthet Surg J. 2015;35:40–47.
  60. Seth AK, Hirsch EM, Fine NA, Kim JYS. Utility of acellular dermis-assisted breast reconstruction in the setting of radiation: a comparative analysis. Plast Reconstr Surg. 2012;130:750–758.
  61. Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010;125:429–436.
  62. Finkelstein ER, Vidal Laureano N, Azizi A, et al. Prepectoral direct-to-implant versus staged tissue expander breast reconstruction: a comparison of complications. Plast Reconstr Surg. 2024;154:224e–232e. Published online ahead of print September 12, 2023.
  63. Asaad M, Morris N, Selber JC, et al. No differences in surgical and patient-reported outcomes among AlloDerm, SurgiMend, and Dermacell for prepectoral implant-based breast reconstruction. Plast Reconstr Surg. 2023;151:719e–729e.
  64. Butterfield JL. 440 Consecutive immediate, implant-based, single-surgeon breast reconstructions in 281 patients: a comparison of early outcomes and costs between SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices. Plast Reconstr Surg. 2013;131:940–951.
  65. Pires GR, Marquez JL, Memmott S, et al. Early complications after prepectoral tissue expander placement in breast reconstruction with and without acellular dermal matrix. Plast Reconstr Surg. 2024;153:1221–1229.
  66. Caputo GG, Marchetti A, Dalla Pozza E, et al. Skin-reduction breast reconstructions with prepectoral implant. Plast Reconstr Surg. 2016;137:1702–1705.
  67. Woo A, Harless C, Jacobson SR. Revisiting an old place: Single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction. Breast J. 2017;23:545–553.
  68. Qiu CS, Seth AK. Early clinical outcomes of polydioxanone mesh for prepectoral prosthetic breast reconstruction. Plast Reconstr Surg Glob Open 2022;10:e4082.
  69. Adams WP Jr, Toriumi DM, Van Natta BW. Clinical use of GalaFLEX in facial and breast cosmetic plastic surgery. Aesthet Surg J. 2016;36:S23–S32.
  70. Pompei S, Evangelidou D, Arelli F, Ferrante G. The use of TIGR matrix in breast aesthetic and reconstructive surgery: is a resorbable synthetic mesh a viable alternative to acellular dermal matrices? Clin Plast Surg. 2018;45:65–73.
  71. Schnarrs RH, Carman CM, Tobin C, Chase SA, Rossmeier KA. Complication rates with human acellular dermal matrices: retrospective review of 211 consecutive breast reconstructions. Plast Reconstr Surg Glob Open 2016;4:e1118.
  72. Sbitany H, Piper M, Lentz R. Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy. Plast Reconstr Surg. 2017;140:432–443.
  73. Paydar KZ, Wirth GA, Mowlds DS. Prepectoral breast reconstruction with fenestrated acellular dermal matrix: a novel design. Plast Reconstr Surg Glob Open 2018;6:e1712.
  74. Baker BG, Irri R, MacCallum V, Chattopadhyay R, Murphy J, Harvey JR. A prospective comparison of short-term outcomes of subpectoral and prepectoral Strattice-based immediate breast reconstruction. Plast Reconstr Surg. 2018;141:1077–1084.
  75. Bettinger LN, Waters LM, Reese SW, Kutner SE, Jacobs DI. Comparative study of prepectoral and subpectoral expander-based breast reconstruction and Clavien IIIb score outcomes. Plast Reconstr Surg Glob Open 2017;5:e1433.
  76. Salibian AH, Harness JK, Mowlds DS. Staged suprapectoral expander/implant reconstruction without acellular dermal matrix following nipple-sparing mastectomy. Plast Reconstr Surg. 2017;139:30–39.
  77. Sorkin M, Qi J, Kim HM, et al. Acellular dermal matrix in immediate expander/implant breast reconstruction: a multicenter assessment of risks and benefits. Plast Reconstr Surg. 2017;140:1091–1100.
  78. Poveromo LP, Franck P, Ellison A, Janhofer DE, Asadourian PA, Otterburn DM. Prepectoral breast reconstruction without the use of acellular dermal matrix: a 3-year review. Ann Plast Surg. 2022;88:S205–S208.
  79. Viezel-Mathieu A, Alnaif N, Aljerian A, et al. Acellular dermal matrix-sparing direct-to-implant prepectoral breast reconstruction: a comparative study Including cost analysis. Ann Plast Surg. 2020;84:139–143.
  80. Delgado JF, García-Guilarte RF, Palazuelo MR, Mendez JIS, Pérez CC. Immediate breast reconstruction with direct, anatomic, gel-cohesive, extra-projection prosthesis: 400 cases. Plast Reconstr Surg. 2010;125:1599–1605.
  81. Jong J, Gabriel A, Trekell M, et al. Cohesive round implants and the risk of implant flipping. Plast Reconstr Surg Glob Open 2020;8:e3321.
  82. Leibl KE, Hwang LK, Anderson C, Weichman KE. A critical analysis of factors associated with anteroposterior implant flipping in immediate breast reconstruction. Ann Plast Surg. 2023;90:S509–S514.
  83. Schwartz JD, Binstock M. Optimizing symmetry after unilateral mastectomy and reconstruction with a less form-stable prepectoral implant. Plast Reconstr Surg Glob Open 2021;9:e3990.
  84. Hammond JB, Foley BM, Kosiorek HE, et al. Seldom one and done: characterizing rates of reoperation with direct-to-implant breast reconstruction after mastectomy. Am J Surg. 2022;224:141–146.
  85. Piper ML, Rios-Diaz AJ, Kimia R, et al. Direct-to-implant versus 2-stage breast reconstruction: which technique is better? An analysis of 104 patients at a single institution. Ann Plast Surg. 2022;89:159–165.
  86. Patel AA, Martin SA, Cheesborough JE, Lee GK, Nazerali RS. The safety and efficacy of autologous fat grafting during second stage breast reconstruction. J Plast Reconstr Aesthet Surg. 2021;74:792–799.
  87. Nemir S, Hanson SE, Chu CK. Surgical decision making in autologous fat grafting: an evidence-based review of techniques to maximize fat survival. Aesthet Surg J. 2021;41:S3–S15.
  88. Luze H, Schwarz A, Philipp Nischwitz S, et al. Autologous fat grafting in reconstructive breast surgery: clinically relevant factors affecting the graft take. Aesthet Surg J. 2022;42:NP745–NP755.
  89. Avila A, Bartholomew AJ, Sosin M, et al. Acute postoperative complications in prepectoral versus subpectoral reconstruction following nipple-sparing mastectomy. Plast Reconstr Surg. 2020;146:715e–720e.
  90. Ostapenko E, Nixdorf L, Devyatko Y, Exner R, Wimmer K, Fitzal F. Prepectoral versus subpectoral implant-based breast reconstruction: a systemic review and meta-analysis. Ann Surg Oncol. 2023;30:126–136.
  91. Zhu L, Liu C. Postoperative complications following prepectoral versus partial subpectoral implant-based breast reconstruction using ADM: a systematic review and meta-analysis. Aesthetic Plast Surg. 2023;47:1260–1273.
  92. Chatterjee A, Nahabedian MY, Gabriel A, et al. Early assessment of post-surgical outcomes with pre-pectoral breast reconstruction: a literature review and meta-analysis. J Surg Oncol. 2018;117:1119–1130.
  93. Alcon A, Rosser M, Gedallovich J, Foster RD, Sbitany H, Piper ML. Long-term outcomes in prepectoral versus subpectoral two-stage implant-based breast reconstruction after nipple-sparing mastectomy. Plast Reconstr Surg. 2023;152:273–280.
  94. Walia GS, Aston J, Bello R, et al. Pre-pectoral versus sub-pectoral tissue expander placement: a clinical and quality of life outcomes study. Plast Reconstr Surg Glob Open 2018;6:e1731.
  95. Sobti N, Weitzman RE, Nealon KP, et al. Evaluation of capsular contracture following immediate pre-pectoral versus sub-pectoral direct-to-implant breast reconstruction. Sci Rep. 2020;10:1137.
  96. Becker H, Lind JG 2nd, Hopkins EG. Immediate implant-based prepectoral breast reconstruction using a vertical incision. Plast Reconstr Surg Glob Open 2015;3:e412.
  97. Li Y, Xu G, Yu N, Huang J, Long X. Pre-pectoral versus sub-pectoral implant-based breast reconstruction: a meta-analysis. Ann Plast Surg. 2020;85:437–447.
  98. Hassan AM, Asaad M, Morris N, et al. Subpectoral implant placement is not protective against postmastectomy radiotherapy-related complications compared to prepectoral placement. Plast Reconstr Surg. 2024;153:24–33.
  99. Sinnott CJ, Persing SM, Pronovost M, Hodyl C, McConnell D, Ott Young A. Impact of postmastectomy radiation therapy in prepectoral versus subpectoral implant-based breast reconstruction. Ann Surg Oncol. 2018;25:2899–2908.
  100. Safran T, Al-Badarin F, Al-Halabi B, Viezel-Mathieu A, Dionisopoulos T. Aesthetic limitations in direct-to-implant prepectoral breast reconstruction. Plast Reconstr Surg. 2022;150:22e–31e.

MeSH Term

Humans
Female
Breast Implants
Breast Implantation
Breast Neoplasms
Pectoralis Muscles
Mammaplasty
Quality of Life
Reoperation
Mastectomy
Journal Article Review

Word Cloud

Created with Highcharts 10.0.0prepectoralbreastreconstructionarticlecurrentDescribeUnderstandtechniquesoutcomesliteraturereviewaddressesLEARNINGOBJECTIVES:studyingparticipantableto:1indicationspatientfactorsrelevantperforming2effectsdifferenttypesimplantsimplantsupport3surgicalrevisionimprove4surroundingclinicalquality-of-lifeSUMMARY:goesbeyondgeneralprovidingworkingframeworkimportantconsiderationssurgeonutilizingalsocontroversiesprovidespracticetipstechnicalpearlsgapsknowledgeopinionPrepectoralBreastReconstruction

Similar Articles

Cited By