Subcutaneous Direct-to-Implant Breast Reconstruction: Surgical, Functional, and Aesthetic Results after Long-Term Follow-Up

Abstract

Direct-to-implant breast reconstruction can be achieved more easily by means of soft-tissue replacement devices such as dermal matrices and synthetic meshes. The feasibility of a subcutaneous approach has been recently investigated by some studies with different devices functioning as implant support. Aim of this study is to analyze the long-term results, both objective and subjective, of a previous nonrandomized trial comparing prepectoral (subcutaneous) and retropectoral breast reconstructions.

Methods: Patients enrolled in a nonrandomized prospective trial, comparing the standard retropectoral reconstruction and the prepectoral subcutaneous approach, using a titanium-coated mesh in both techniques, were followed up and evaluated for long-term results. Cases were compared in terms of the causes and rate of reinterventions, of the postoperative BREAST-Q questionnaire results, and of an objective surgical evaluation.

Results: The subcutaneous group had a rate of implant failure and removal of 5.1% when compared with 0% in the retropectoral group. Aesthetic outcome was significantly better for the subcutaneous group both at a subjective and at an objective evaluation. Capsular contracture rate was 0% in the subcutaneous group.

Conclusions: A higher rate of implant failure and removal, although not significant, always because of skin flaps and wound problems, should be taken into account for a careful patients selection. The subcutaneous breast reconstruction shows good long-term results. A coherent subjective and objective cosmetic advantage of this approach emerges. Moreover, no capsular contracture is evident, albeit in a relatively limited number of cases.

Fig.1.

Implant preparation. Complete implant wrapping by means of a TCPM.

Fig. 2.

Subcutaneous implant positioning. The implant and the mesh are placed directly underneath the skin flaps in a prepectoral position.

Fig. 3.

Subcutaneous implant fixation. Few interrupted stitches are placed between the mesh and the muscular fascia to secure the implant in the desired position.

Fig. 4.

Retropectoral implant position. Implant in the traditional retropectoral pocket created by dissecting the muscle from chest wall.

Fig. 5.

Prepectoral, subcutaneous, implant position. Implant in the subcutaneous space, above the muscle, which is not dissected.

Fig. 6.

Subcutaneous, muscle-sparing, direct-to-implant breast reconstruction. Unilateral breast reconstruction without any surgical procedure on the contralateral side.

Fig. 7.

Subcutaneous, muscle-sparing, direct-to-implant breast reconstruction. Unilateral breast reconstruction without any surgical procedure on the contralateral side.

Fig. 8.

Subcutaneous, muscle-sparing, direct-to-implant breast reconstruction. Bilateral mastectomy with a bilateral direct-to-implant subcutaneous reconstruction using the same implant and technique on both sides.

Fig. 9.

Titanium-coated synthetic mesh integration within capsule. Appearance of capsule during a second-stage procedure, after tissue expander removal of a reconstructed breast by means of a TCPM. The synthetic mesh results completely integrated within the capsule, which results in thin and soft tissues.

Fig. 10.

Microscopic appearance of titanium-coated synthetic mesh integration within capsule. Fibrous capsule shows regular cystic spaces containing pale material consistent with the TCPM, surrounded by a mild chronic inflammatory response with histiocytes and foreign body giant cells. These elements are completely integrated within fibroblastic tissue.

Video 1.

See Video, Supplemental Digital Content 1, which displays cosmetic long-term result of a bilateral subcutaneous breast reconstruction, bilateral mastectomy with direct-to-implant subcutaneous breast reconstruction in a skinny woman and appearance at 24 month follow-up, in a patient submitted to systemic adjuvant chemotherapy and postoperative radiation therapy on the right side. This video is available in the “Related Videos” section of the full-text article on http://www.PRSGO.com or available at http://links.lww.com/PRSGO/A152.