Plastic Surgery Research Council

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Clinical Outcomes in Prepectoral Stage 1 Breast Reconstruction
Shanique Martin, BS1, Elizabeth Turner, PA-C2, Brian Thornton, MD2, Rahim Nazerali, MD, MHS3.
1Stanford University, Palo Alto, CA, USA, 2ThorntonMD, Louiseville, KY, USA, 3Division of Plastic and Reconstructive Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA.

PURPOSE:
Plastic surgeons are increasingly exploring prepectoral breast reconstruction as an option for their patients, but there is little evidence on clinical outcomes to guide this decision-making process. The placement of a prosthetic device superficial to the pectoralis major muscle is an attractive breast reconstruction technique addressing the issue of animation deformity and incurring less postoperative pain. Emphasis is often on appropriate patient selection with obesity, tobacco use and prior breast irradiation being listed as relative contraindications to immediate prepectoral breast reconstruction. Here we present a large series of patients from a single surgeon database on prepectoral reconstruction outcomes.
METHODS:
We performed a retrospective review of a prospectively maintained database on prepectoral implant-based breast reconstructions, between January 1, 2017 - October 30, 2018. All patients who were at least 30 days postoperative after tissue expander placement (stage 1) reconstruction were eligible for inclusion in the study.
RESULTS:
There were 169 patients who underwent stage 1 breast reconstruction with prepectoral tissue expander placement. Overall, 135 patients (average age 51.1 years) were included in the study. Postoperative follow-up ranged from 1.2 months (36 days) to 20.5 months (628 days) with a median of 5 months (153 days).
The average BMI was 27.3 kg/m2 with 37 patients (27.4%) classified as obese. The prevalence of diabetes and tobacco history were each 5%. There were 28 patients (20.7%) who received neoadjuvant chemotherapy and 9 patients (6.7%) with prior breast irradiation. Nipple sparing mastectomies were performed in 73 patients (54%) and 108 patients (80%) underwent bilateral reconstruction. Immediate tissue expander insertion after mastectomy was performed in 111 patients (82%). Complete anterior coverage of the tissue expander with acellular dermal matrix (ADM) was performed in 86% of the immediate reconstruction cases and ADM was used in 25% of the delayed reconstruction cases. There were 33 patients (24%) who received postoperative oral antibiotics for greater than 24 hours following the procedure. The overall rate of complications following stage 1 reconstruction was 23%, with 6 patients experiencing multiple complications. Surgical site infection (23 patients, 17%) and flap and/or nipple necrosis (14 patients, 10%) were the most common complications. There was 1 complication of incision dehiscence. Multivariate analysis demonstrated that both obesity and immediate reconstruction were associated with increased risk of surgical site infection (OR 4.7, p= 0.006 and OR 12.4, p=0.028), though neither were associated with flap necrosis.
CONCLUSIONS:
The rates of prepectoral breast reconstruction have increased in the past 5 yrs. Limited data exists in the literature describing the safety and rates of complications for this procedure in a large population. This review of a single surgeon's experience with prepectoral breast reconstruction provides additional support for the continued adoption of this technique, given appropriate patient selection and counseling.

Table 1. Patient Factors and Rates of Surgical Site Infection
VariableNo Infection
(n=112)
Infection
(n=23)
p-value
Age (25-74)50.87 (9.80)51.19 (11.04)0.899
BMI (17.7 - 42.50)27.20(5.50)27.97 (5.29)0.538
Obesity28 (25%)9 (39.1%)0.201*
Hypertension23 (20.5%)6 (26%)0.581
Diabetes6 (5.4%)1 (4.3%)1
History of Tobacco Use 7 (6.3%)0 (0%)-
Prior Augmentation12 (10.7%)4 (17.4%)0.476
Neoadjuvant Chemotherapy 22 (19.6%)4 (17.4%)1
History of Breast XRT8 (7.1%)1 (4.3%)1
Nipple Sparing Mastectomy 61 (54.5%)12 (52.2%)1
Bilateral Reconstruction89 (79.4%)19 (82.6%)1
Immediate Recon89 (79.4%)22 (95.7%)0.076*
ADM Type0.376
No ADM30 (26.8%)3 (13%)
Alloderm24 (21.4%)6 (26.1)
FlexHD58 (51.8%)14 (60.9%)
Post-Op Abx >24hrs 28 (25%)5 (21.7%)1
Adjuvant Chemotherapy (n=131)41 (36.6%)7 (30.4%)1
Adjuvant XRT (n=131)25 (22.3%)5 (21.7%)0.778
Mastectomy Surgeon0.119*
#151 (45.5%)10 (43.5%)
#236 (32.1%)6 (26.1%)
#34 (3.6%)4 (17.4%)
Other21 (18.8%)3 (13%)

Table 2. Multivariate Logistic Regression Analysis of Factors Predictive of Surgical Site Infection
FactorOdds Ratio95% CIp-value
Obesity4.661.56-14.090.006*
Immediate Reconstruction12.441.85-255.150.028*
Mastectomy Surgeon #10.650.15- 3.550.587
Mastectomy Surgeon #24.990.71-40.840.113
Mastectomy Surgeon #30.640.13-3.640.589


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