Prepectoral Breast Reconstruction: A Technical Algorithm

Abstract

Despite falling out of favor in the 1970s, prepectoral breast reconstruction has resurfaced in the recent years as a safe and effective alternative to subpectoral/partial subpectoral breast reconstruction in carefully selected patients. This article outlines an algorithmic technical approach to prepectoral breast reconstruction for new patients and revision patients.

Fig. 1.

Prepectoral reconstructive approach to new or revision patients. *Point of decision making with regard to ADM insetting technique. NSM indicates nipple-sparing mastectomy; SSM, skin-sparing mastectomy.

Fig. 2.

TE wrapped with ADM ex vivo using “wonton” technique. A, Right breast ADM device complex anterior surface. B, Right breast ADM device complex posterior surface. C, Left breast ADM device complex anterior surface. D, Left breast ADM device complex posterior view.

Fig. 3.

Forty-six–year-old woman who underwent immediate 2-stage prepectoral breast reconstruction via “wonton” technique after bilateral nipple-sparing mastectomy. Picture taken 6-week status post stage 2 prepectoral breast reconstruction.

Fig. 4.

“Ravioli” technique-2 ADMs covering anterior and posterior surface of prosthetic device. (Adapted with permission from Sigalove. Copyright 2018 by the American Society of Plastic Surgeons.)

Fig. 5.

Anterior tenting technique-cuff along the IMF. (Adapted with permission from Sigalove. Copyright 2018 by the American Society of Plastic Surgeons.)

Fig. 6.

An illustration of the sequential suture technique for left (A) and right (B) chest.

Fig. 7.

Prepectoral breast reconstruction using sequential suturing technique on unilateral left-sided skin-sparing mastectomy. A, The breast pocket immediate post mastectomy and after hemostasis. B, ADM marked at the 12 o’ clock position and placed inside the breast pocket. C, First suture started at 12 o’ clock position. D, Lateral opening with ADM pulled up. E, Placement of the TE through the lateral opening. F, Uninflated TE placed on top of the pectoralis muscle and under the ADM via lateral opening. G, TE inflated with air after closing the lateral border.

Fig. 8.

Forty-five–year-old woman who underwent immediate 3-stage prepectoral breast reconstruction via sequential suture technique after bilateral skin-sparing mastectomies. Picture was taken 6-week status post stage 3 breast reconstruction.

Fig. 9.

Illustration depicting conversion of a partial muscle coverage with lower pole ADM to prepectoral reconstruction.