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The Frequency And Type Of Requested Revisions Associated With Breast Reconstruction In The Subpectoral And Prepectoral Plane
Alan T. Nguyen, BS1, Fara Dayani, BS2, Jennifer Cheesborough, MD3, Rahim Nazerali, MD, MHS, FACS3.
1Oakland University William Beaumont School of Medicine, Auburn Hills, MI, USA, 2University of California, San Francisco, San Francisco, CA, USA, 3Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA.

PURPOSE: Implant-based breast reconstruction outnumbers autologous reconstruction in many centers, and provides patients with a psychosocial benefit. However, multiple surgeries are often required to achieve a desired aesthetic result. Identifying patient-driven indications for revision may guide initial surgical planning.
METHODS: Retrospective single-institution review of 114 patients from 2013-2018 who have undergone implant-based reconstruction and now request revisionary surgery.
RESULTS: 98 (86%) reconstructions were initially done in the subpectoral plane with 32 (32.7%) of these patients requesting an additional secondary revision. 16 (14%) were prepectoral reconstructions with 4 (25%) requesting secondary revision. Volume correction and implant migration were the most common patient-driven indications for revision shared by both subpectoral and prepectoral reconstructions without the proportion for each request differing between each plane of reconstruction, p=0.14 and p=0.11 respectively. Within the subpectoral cohort, volume correction (60.2%) was requested at a significantly higher rate than lesser reasons of implant migration (16.3%, p=8.3E-11) and irregular breast contour when the pectoralis was relaxed (28.6%, p=5.6E-5). Within the prepectoral cohort, volume correction did not significantly differ from the lesser reasons of implant migration (25%, p=0.15) or asymmetry (25%, p=0.15).
9 implants were exchanged from the sub-to-prepectoral plane. Of these 9, 6 patients desired resolution of animation deformity and 3 exchanges were due to superior prosthetic displacement. Prepectoral conversion effectively resolved animation deformity and also enabled reconstruction of the inframammary fold to house the prior superiorly displaced implants. 2 reconstructions were exchanged pre-to-subpectoral to provide additional soft tissue support to the prosthetic as both patients experienced bottoming-out. However, one individual required a 3rd revision for an ADM sling due to continued bottoming out and the other started experiencing pain over the breast after revision.
CONCLUSION: This study identifies the common reasons why patients elect to undergo secondary procedures. Patients who undergo initial reconstruction in the subpectoral plane are more likely to undergo first and secondary revisions than prepectoral reconstructions. Within our patient cohort, sub-to-prepectoral conversion provided a functional and aesthetic benefit while subpectoral conversion continued to give patients unsatisfactory results.


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