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Pre-pectoral Or Sub-pectoral Tissue Expander-based Breast Reconstruction - A Propensity-matched Analysis Of Clinical And Health Related Quality Of Life Outcomes
Jonas A. Nelson, MD1, Meghana G. Shamsunder, MPH1, Thais O. Polanco1, Robert J. Allen, Jr., MD1, Colleen M. McCarthy, MD1, Evan Matros, MD, MMSc, MPH1, Michelle Coriddi, MD1, Joseph Dayan, MD1, Peter G. Cordeiro, MD1, Babak J. Mehrara, MD1, Andrea L. Pusic, MD, MHS, FACS, FRCSC1,2, Joseph Disa, MD1.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, Boston, MA, USA.

PURPOSE:
Pre-pectoral placement of tissue-expanders for two-stage implant-based breast reconstruction has become an accepted option, potentially minimizing chest wall morbidity and altering the pain profile of this procedure. Large scale studies examining effectiveness, complications and health related-quality of life(HR-QoL) are lacking. This study aims to explore 90-day clinical and HR-QoL outcomes for pre-pectoral versus sub-pectoral TE breast reconstruction.
METHODS:
Propensity score matching analysis (nearest neighbor, 1:1 matching without replacement) was performed for pre-pectoral and sub-pectoral patients. Matched covariates included age, body mass index(BMI), race/ethnicity, smoking status, chemotherapy, radiotherapy, nipple-sparing mastectomy, axillary lymph-node dissection, and laterality of reconstruction. Outcomes of interest were physical well-being of the chest(PWB-Chest) BREASTQ scores and complications.
RESULTS:
983 patients were evaluated with 262 patients analyzed after matching. The matched cohort had no differences in baseline characteristics. Although pre-pectoral patients had significantly higher preoperative PWB-Chest scores(p<0.001), postoperative scores did not differ significantly. However, in a subgroup analysis assessing PWB-Chest scores by laterality, bilateral pre-pectoral patients had higher scores at 6-weeks(p=0.001). Within 90-days postoperatively, pre-pectoral patients had higher rates of breast seroma than sub-pectoral patients(p=0.002).
CONCLUSION: In a matched analysis of early 90-day complications, pre-pectoral tissue expanders had a significantly higher rate of breast seromas compared to sub-pectoral reconstruction, though did not differ in expander loss. Patient reported PWB-Chest did not differ postoperatively, however subgroup analysis suggests PWB-Chest scores are improved at 6-weeks for bilateral pre-pectoral patients. Continued long-term analysis of clinical and patient reported outcomes are warranted to understand the full profile of this technique.


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