Plastic Surgery Research Council

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Prepectoral versus Subpectoral plane Tissue Expander Based Breast Reconstruction: An Analysis of Complications, Outcomes and Cost Utility
Franca Kraenzlin, Halley Darrach, Nima Khavanian, Kristen Broderick, Michele Manahan, Gedge Rosson, Oluseyi Aliu, Damon Cooney, Justin Sacks.
Johns Hopkins, Baltimore, MD, USA.

PURPOSE: Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. With this growing patient base, the techniques and technologies behind prosthesis-based reconstruction have continued to evolve - particularly with respect to the anatomic placement of such devices. The availability of tissue replacement matrix, implants and surgical techniques has ushered in a revival of prepectoral tissue expander (TE) placement. Studies have already demonstrated many benefits of prepectoral reconstruction and we aimed to further examine the outcomes of patients undergoing immediate breast reconstruction with TEs with respect to anatomic placement.
METHODS: An IRB approved retrospective review of all adult post-mastectomy patients receiving TEs was completed for a one-year period (2017) at an academic medical center (n=178). Patient demographics, operating room charges, anesthesia length, length of hospital stay, post-operative complications, and average time to reconstruction were compared through a review of the medical records.
RESULTS:
A total of 178 patients underwent mastectomy followed by TE placement. The number of patients receiving prepectoral TEs compared to subpectoral TEs were split exactly at 50% (n=89). Subpectoral and prepectoral patient groups were similar in age, average mastectomy weight, length of stay, rates of neoadjuvent chemotherapy or radiation, and rates of post-mastectomy chemotherapy and radiation. The prepectoral patient group was statistically more likely to receive a nipple-sparing mastectomy and to have tissue replacement matrix used as part of the reconstruction.Individuals with a prepectoral TE underwent definitive reconstruction 39.4 days earlier than individuals with subpectoral TE placement (154.2 days vs. 193.7 days, p=0.01, respectively). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (56.8 less minutes, p=<0.001) or unilateral (30.8 minutes less, p=<0.001). Operating room cost has higher in the prepectoral subgroup ($30,997.3 vs. $22,204.1, p-<0.001, respectively), with the largest contributor to the cost difference stemming from the amount of tissue replacement matrix used. Immediate and delayed complication rates were similar between the patient groups. The rate of hematoma formation requiring evacuation was similar between the groups (2.2% prepectoral vs. 4.5% subpectoral, p=0.41). Delayed complications rates including seroma development, breast erythema, infection, and TE explanation for infection were not statistically different.
CONCLUSION:
Breast reconstruction using prepectoral tissue expander based reconstruction is a safe alternative to subpectoral reconstruction with patients benefiting from less anesthesia time and shorter time to definitive reconstruction, at the compromise of higher operating room costs. However, with significantly shorter operative times and decreased time to final reconstruction further quality of life and financial analysis are warranted specifically in regards to the utility of tissue replacement matrix. No conclusions are to be drawn concerning aesthetic or functional outcomes. However, this study logically requires us to investigate them in the future.


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