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Patient Satisfaction, Patient-reported Outcomes, And Clinical Outcomes Following Prepectoral Breast Reconstruction With Fenestrated Acellular Dermal Matrix
Jennifer E. Fligor1, Allison Hu, B.S.1, Garrett A. Wirth, MD, MS, FACS2, Donald S. Mowlds, MD3, Gregory Evans1, Keyianoosh Z. Paydar, MD, FACS1.
1University of California - Irvine, Orange, CA, USA, 2Wirth Plastic Surgery, Newport Beach, CA, USA, 3Donald S. Mowlds, MD Plastic and Reconstructive Surgery, Newport Beach, CA, USA.

Purpose
Prepectoral (PP) breast reconstruction and use of acellular dermal matrix (ADM) are associated with beneficial outcomes in breast reconstruction. Data on patient satisfaction and patient-focused outcomes with PP reconstruction are limited in the literature, and many of the benefits claimed are anecdotal. This study aims to compare surgical outcomes and patient satisfaction between PP and subpectoral (SP) implant placement in reconstruction with fenestrated ADM (fADM).
Methods
Patients who underwent one-or-two stage immediate PP or SP implant-based breast reconstruction with FlexHD fADM by the senior author between January 1, 2016 and July 31, 2018 were included in the study. Demographic, treatment, and surgical outcome data were retrospectively collected from the medical record. Patient-reported outcomes were surveyed using Breast-Q (BQ) modules and questions evaluating self-reported capsular contracture and post-operative complications, pain, and narcotic use.
Results
A total of 44 patients (PP n=16, SP n=28) and 72 breasts (PP n=30, SP n=42) were included. Demographics did not differ significantly between PP and SP patients. Mean clinical follow-up: 352.41 days. 30-day post-operative complication rate: 23.6% (PP 33.3%, SP 16.7%, p= 0.1584). Baker grade capsular contracture did not differ significantly between groups: I 91.7% (PP 96.7%, SP 88.1%), II 5.6% (PP 3.3%, SP 7.1%), III 1.4% (PP 0.0%, SP 2.4%), IV 1.4% (PP 0.0%, SP 2.4%). Average time to drain removal was shorter in PP compared to SP breasts reaching statistical significance (9.274.20 vs 13.866.26 days, p=0.0008). Preliminary survey data (PP n =4, SP n=7) follows: BQ Satisfaction with Breasts Equivalent Rasch Transformed Score (ERTS) PP 69.00, SP 63.86; BQ Satisfaction with Implants Score PP 5.50, SP 6.29; BQ Psychosocial Well-Being ERTS PP 70.00, SP 60.00; BQ Physical Well-Being: Chest ERTS PP 82.00, SP 63.14. Similar mean BQ score for ipsilateral arm lymphedema, (PP 1.00, SP 1.43) and mean self-reported capsular contracture grade (PP 2.25, SP 2.29) were found. Average post-operative pain ratings (0-10 scale) were PP 4.25, SP 3.71. Rates of self-reported complications follow: hematoma (PP 0, SP 0), seroma (PP 0.5, SP 0.14), infection requiring IV antibiotics in hospital (PP 0.25, SP 0.29), red breast syndrome (PP 0.75, SP 0.43), visible distortion of implant shape with chest muscle contraction or leaning forward (PP 0.5, SP 0.71), other complication requiring hospitalization or intervention (PP 0.5, SP 0.28). Post-operative narcotic use trended higher in the SP group.
Conclusions
This study builds upon a prior published study of PP reconstruction with fADM with the addition of a patient survey, which may both 1) capture complications or capsular contracture occurring after the duration of clinical follow-up and 2) provide insight into patient satisfaction after PP and SP reconstruction. There was no significant difference in 30-day complication rate between groups. However, time to drain removal was shorter for PP breasts, and preliminary survey data demonstrate trends favoring PP reconstruction: Satisfaction with Breasts, Psychosocial Well-Being, and Physical Well-Being: Chest ERTS were higher for PP compared to SP, and post-operative narcotic use trended lower for the PP group. These findings suggest improvements in the patient experience with PP reconstruction.


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