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A Historically Controlled Comparison: Does Switching To Prepectoral Tissue Expander Placement Affect Complications?
Yash Kadakia, BA1, Ricardo Garza, BS1, Julie L. Cooper, BS1, Avinash Jayaraman, BA1, Sami U. Khan, MD2, Nicholas T. Haddock, MD1, Sumeet S. Teotia, MD1.
1University of Texas Southwestern Medical Center, Dallas, TX, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE: The rising popularity of prepectoral tissue expander placement with acellular dermal matrices (ADMs) in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive controlled trial comparing postoperative outcomes following prepectoral vs. subpectoral placement of tissue expanders is lacking.
METHODS: Retrospective cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onwards (n=260). In 2017, the reconstructive surgeons switched their standard of care from subpectoral tissue expander placement to prepectoral placement without change in patient selection criteria. However, the mastectomy surgeons continued to practice the same surgical technique, thus establishing an internal historical control. Patients were divided by tissue expander placement: prepectoral (n=122) vs. subpectoral (n=138). Patient demographics, co-morbidities, intra-operative factors, and postoperative outcomes were compared with 2 proportion z tests for categorical data, Student's t tests for parametric data, and the Mann-Whitney U test for nonparametric data.
RESULTS: There were no differences between groups in age, race, BMI, hypertension, diabetes, OR time, and tissue expander size. Compared to subpectoral placement, prepectoral placement resulted in similar rates of overall postoperative complications (30% vs 30%, p=0.97), including hematoma (2% vs 3%, p=0.50), seroma (7% vs 9%, p=0.70), impaired wound healing (21% vs 20%, p=0.84), and infection (12% vs 10%, p=0.58). Furthermore, prepectoral placement resulted in similar a rate of complications that required a return to the OR (18% vs 17%, p=0.77), including treatment for hematoma (2% vs 2%, p=0.75), seroma (3% vs 6%, p=0.33), wound necrosis (10% vs 12%, p=0.53), and wound dehiscence (3% vs 2%, p=0.58). Prepectoral placement was not associated with increased likelihood of explant (4% vs 4%, p=0.84), expander exchange (4% vs 3%, p=0.60), or OR washout (9% vs 12%, p=0.50).
Prepectoral placement was not associated with prolonged time to drain removal (19 days vs. 17 days, p=0.13). However, patients who underwent prepectoral placement completed the expansion process twice as fast (27 days vs. 61 days, p=1.2E-8), were expanded further in the OR (445 cc vs. 343 cc, p=1.1E-6), and were more than twice as likely to forgo clinic-based expansion (54% vs. 20%, p=1.5E-9).
CONCLUSION: Prepectoral tissue expander placement offered greater intra-operative filling of expanders and a reduced likelihood of clinic-based expansion with no increase in adverse outcomes compared to subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits, shorten the delay before adjuvant therapy, and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.


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