Current status of pre- and retropectoral breast reconstructions worldwide: a narrative review

Abstract

Background and objective: Advances in breast cancer research and technology contribute to conservative ablative surgical approach with emphasis on reconstruction. The introduction of biologic membranes in breast surgery facilitates a one-stage implant reconstruction while the importance of the pectoralis major muscle involvement in the procedure becomes debatable. A subsequent increase in prepectoral implant placement procedures seems to close a cycle of innovations in implant-based breast reconstructions. This sparks a debate that calls for a critical review of existing literature considering that new challenges tend to arise along with new perspectives. The authors seek to scope the present status of prepectoral and subpectoral implant reconstruction worldwide, and answer recurring questions, including the novelty of presented innovations in the context of existing literature.

Methods: The article is based on a literature search in PubMed with the keywords "prepectoral" or "subpectoral" and "breast reconstruction", in addition to the authors' experience with a large number of patients.

Key content and findings: Recent studies focus on the comparative safety of prepectoral vs. subpectoral placement debating the use of biologic vs. non-biologic sheets and implant texture. There seems to be more emphasis on early post-operative safety of the procedures, rather than any long-term prospects of their comparison, up to this point. Skin and nipple sparing mastectomy (SSM/NSM) together with biological membranes have played a key role in current practice and cannot be overlooked.

Conclusions: After reading this paper, the reader should have a firm understanding of the key elements of implant-based breast reconstruction in historical context with emphasis on muscle planes and their pros and cons.

Keywords: Implant-based breast reconstruction; acellular dermal matrix (ADM); biologics; prepectoral; retropectoral.

Figure 1

A 30-year-old breast cancer patient. NSM DIR reconstruction, high profile 300 cc Motiva Silk Surface^® implants ADM hammock in prepectoral position. Preoperative and one year post-operative. NSM, nipple sparing mastectomy; DIR, direct-to-implant; ADM, acellular dermal matrix.

Figure 2

Late rippling with prune appearance of the upper pole when leaning forward.

Figure 3

A 28-year-old breast cancer patient. NSM DIR reconstruction prepectoral anatomical Mentor 260 cc implants and no ADM. Early postoperative results showed capsular contraction, displacement of the implants and pressure necrosis on the IMF scar on the right, indicating just about every possible adverse outcome of the prepectoral procedure. NSM, nipple sparing mastectomy; DIR, direct-to-implant; ADM, acellular dermal matrix; IMF, inframammary fold.

Figure 4

The same patient as in Figure 3. Nine months after corrective procedure with implant change to dual plane with ADM, round silk surface high profile Motiva^® implants 260 and 40 cc fat transfer to the upper and medial pole. This illustrates how dual plane and ADM along with autologous fat grafting can be useful in difficult situations. ADM, acellular dermal matrix.