Plastic Surgery Research Council

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Evaluation Of Capsular Contracture Rate Following Immediate Prepectoral Versus Subpectoral Direct-to-implant Breast Reconstruction
Nikhil Sobti, BA, Rachel E. Weitzman, MS, Kassandra P. Nealon, BA, William G. Austen, Jr., MD, Eric C. Liao, MD, PhD.
Massachusetts General Hospital, Boston, MA, USA.

PURPOSE: Few studies have evaluated the impact of breast irradiation on capsular contracture rate within patients undergoing prepectoral direct-to-implant (DTI) breast reconstruction. Additionally, current systems of classification for capsular contracture rely on subjective evaluation by the surgeon. It stands to reason that change in anatomic landmark positioning over time may serve as a surrogate measure for contracture of the breast mound. The authors hypothesize that prepectoral DTI breast reconstruction will be associated with lesser deviation in anatomic landmark positioning compared to subpectoral implant placement within an irradiated patient population.
METHODS: Retrospective review of patient photographs was performed to identify consecutive bilateral DTI reconstruction procedures performed at a tertiary academic medical institution over 4 years. Only those patients who underwent post-operative radiation therapy were included. The following landmarks were identified by a blinded reviewer: inframammary fold (IMF), nipple (N), and superior pole of the breast. Changes in distance between the sternal notch and the aforementioned landmarks were calculated and compared between groups. Importantly, the non-irradiated contralateral breast was used as a control to determine the percent deviation in landmark positioning from baseline following radiation therapy. Univariate analyses were conducted to compare objective endpoints across the implant positioning groups.
RESULTS: Of the 25 patients captured for review, 16 (64%) underwent subpectoral DTI breast reconstruction, whereas the remaining 9 (36%) underwent direct prepectoral implant placement. Subpectoral breast reconstruction was associated with a greater percent deviation in positioning of the inframammary fold (6.8 5.3% v. 3.8 3.9%) and superior pole of the breast (17.5 8.1% v. 11.4 7.4%) when compared to prepectoral reconstruction, however the result did not achieve significance (p = 0.17 and p = 0.12, respectively). However, we did observe a significant difference in nipple positioning, with subpectoral DTI breast reconstruction presenting with greater deviation when compared to prepectoral reconstruction (7.1 7.5% v. 2.1 0.9%, respectively, p = 0.01).
CONCLUSION: These results suggest that prepectoral DTI breast reconstruction may be associated with lower rate of landmark deviation within the context of breast irradiation when compared to subpectoral reconstruction. The emergence of techniques for prepectoral breast reconstruction has rendered evaluation of surgical outcome within an irradiated patient population necessary to refine surgical technique and improve patient counseling with regard to immediate implant-based breast reconstruction.


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