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Assessing Aesthetic Outcomes In Implant-based Breast Reconstruction: Is There A Difference Amongthe Shape And Location Of The Implant?
Joseph Banuelos, MD, Jason Weissler, MD, Jesse Meaike, MD, Omar Mohamed, MD, Nichole Zayan, MD, Joanne Song, MD, Minh-Doan Nguyen, MD, PhD, Nho V. Tran, MD, Christin A. Harless, MD.
Mayo Clinic, Rochester, MN, USA.

PURPOSE:
Although the landscape of breast reconstruction continues to evolve, the fundamental principle of restoring form and function in an aesthetically-pleasing fashion remains unchanged. With an emphasis on achieving aesthetic outcomes in the setting of implant-based breast reconstruction (IBR), significant effort has been invested into scrutinizing the nuances between both implant type (smooth versus anatomic/textured), as well as implant pocket location (prepectoral versus subpectoral). Historically, submuscular implant placement has been demonstrated to safely and reliably deliver aesthetic outcomes. However, as prepectoral reconstruction continues to gain increased recognition and adoption, recent research has been concentrated on deciphering the aesthetic superiority of one technique over another. This study aims to compare the aesthetic outcomes following prepectoral and subpectoral IBR using either smooth or anatomic implants.
METHODS:A single-institutional retrospective review was performed to identify consecutive patients who underwent IBR following nipple-sparing mastectomies. Patients were divided in 2 groups (prepectoral vs subpectoral) and were matched based on age, ethnicity, date of surgery and implant size. Six-month postoperative photographs following IBR were collected and assessed. A blinded, randomized assessment was performed by plastic surgeons, senior plastic surgery residents, and fellows. The evaluation tool included a 5-point Likert scale to evaluate symmetry of the nipple-areolar complex, breast symmetry, shape, and size, in addition to scar appearance, and position of the inframammary fold. A global aesthetic score was calculated for each patient (1-5). Additionally, blinded evaluators were asked whether they could determine the type of reconstruction (prepectoral vs subpectoral) and the type of implant (round vs anatomical) for each patient. Comparative analysis of continuous variables and categorical variables were performed using the Mann-Whitney-Wilcoxon and Fisher's exact tests, respectively. A value of p < 0.05 was considered significant.
RESULTS:A total of 44 patients were included and evaluated in this study. Overall, 20 patients underwent subpectoral reconstruction, whereas 24 underwent prepectoral reconstruction. Regarding implant type, 25 (56.8%) patients had anatomic implants, and 19 (43.2%) had round implants placed. There was no difference in implant size, BMI, and ethnicity of the patients. Ten evaluators participated in the study, for a total of 440 aesthetic assessments. The median global aesthetic evaluation was higher in the prepectoral group (3.9) than in the subpectoral (3.7) group. However, this difference was not statistically significant (p=0.225). Similarly, the median global score was higher for patients with anatomic implants (3.9) than for patients with round implants (3.6), p=0.513. Evaluators accurately identified prepectoral reconstruction in 75% of the patients, but only correctly identified 25% of the subpectoral implant reconstructions (p=0.0001). Lastly, evaluators were unable to distinguish round (50%) from anatomical (50%) implants (p=0.880).
CONCLUSION:This study demonstrates that round implants provide comparable aesthetic outcomes to anatomic devices in patients who underwent IBR . Additionally, aesthetic outcomes are comparable amongst patients who underwent prepectoral or subpectoral reconstruction. Although evaluators correctly identified patients who underwent prepectoral reconstructions, they were not successfully able to distinguish anatomical from round devices.


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