DISCUSSION Discussion: Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy Allen Gabriel, M.D. G. Patrick Maxwell, M.D. Loma Linda, Calif.; and Vancouver, Wash.
T
he number of implant-based reconstructions continues to increase yearly, as breast reconstructions remain in the forefront of breast cancer surgery. The keystone to the improved quality of reconstructive outcomes has been the refinements in operative techniques, now practiced by oncologic breast surgeons, working closely with plastic surgeons, as they understand the importance of the preservation of oncologic sound mastectomy flaps.1 The advances in the availability of more cohesive and higher fill implants, scaffolds (acellular dermal matrices), and regenerative cells (processed fat with good quality) have revolutionized modern day breast reconstruction, and now we speak of “aesthetic breast reconstruction.”2 The dual-plane technique has been the standard of care in breast reconstruction and has been validated by many surgeons.3 Thus, to deviate from this gold standard, proof of new technique validation is needed, as one of the most recent advances has been the reintroduction of prepectoral reconstruction technique following mastectomy, where the pectoralis major is not manipulated or violated.4 This has led to easier recovery postoperatively and even improved aesthetic results because of the lack of animation deformity.5 Prepectoral breast reconstruction, a failed technique from the past, is now being resurrected by means of use of the regenerative constructs used in combination with advanced surgical devices and techniques. As this concept runs counter to our evolved current approach of the necessity for well-vascularized muscle cover over devices, we must document our outcomes and validate patient outcomes. Thus, we would like to congratulate the authors of this article for their contribution to this important topic. From the Department of Plastic Surgery, Loma Linda University Medical Center; and PeaceHealth Plastic Surgery. Received for publication May 12, 2017; accepted May 12, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003684
444
In this article, they have compared, prospectively, their standard “dual-plane” two-stage reconstruction technique series [using 6 × 16-cm AlloDerm (LifeCell Corp., Branchburg, N.J.)] to their prepectoral two-stage reconstruction (using 16 × 20-cm AlloDerm). Their results further confirm, as we and others have shown,4,6 that the feared complications of immediate reconstruction in prepectoral reconstruction are not different from those associated with the traditional dual-plane reconstruction. One early concern of surgeons and criticism of prepectoral reconstruction has been the fear of developing increased seromas, because of the large pieces of acellular dermal matrices that are used during this surgery. To avoid this feared complication in immediate reconstruction, we advocate meticulous pocket work for both dual-plane and prepectoral reconstructions. Lateral chest wall tissue is rotated from the posterior axillary line toward the anterior axillary line to further collapse the pocket. In the cephalad portion of the pocket, similar techniques are used to minimize the dead space as much as possible, especially in the prepectoral location, where we are directly placing the device and acellular dermal matrix. We agree with the authors that the technical placement of the acellular dermal matrix is critical, as one must ensure stability of the fold and the lower pole. This is achieved by the 3- to 4-cm overlap of the caudal portion of the acellular dermal matrix onto the chest wall to support the expander and future implant and allow for the gutter effect, enveloping the lower expander anteriorly and posteriorly.4 The weight load is redistributed throughout the acellular dermal matrix to the chest wall acellular dermal matrix. This further leads to creation of a crisp inframammary fold, as the implant and the expander will dictate the shape of the reconstructed breast. Disclosure: The authors are consultants for Allergan, Inc. No funds were received or utilized.
www.PRSJournal.com
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Discussion Biodimensional planning concepts remain a cornerstone in preoperative planning where the planned, probable final implant must be anticipated. This allows for an understanding of what the desired final width of the implant is going to be, regardless of shape (round versus anatomical) or even projection. Using this principle, an expander is then chosen that is at least 0.5 to 1 cm narrower. Whether performing a dual-plane or prepectoral reconstruction, all expanders are underfilled rather than overfilled and, at times, air (considered to be off-label) is used instead of saline. The underfilling of the expander is important, as this will help with the preparation of the new site for the placement of the future implant. This new site (pocket) should be snug for the future implant to allow for the implant to shape the breast long term. It is not unusual in our practice to place a 400-cc expander followed by an extra-projecting 800-cc implant in higher body mass index patients if this is the desire of the patient. Smaller expanders give the surgeon a great deal of flexibility when dealing with both anatomically shaped and round shaped implants. Thus, biodimensional planning and technical execution steps have stood the test of time and are as applicable to prepectoral breast reconstruction as to subpectoral or submuscular breast reconstruction. The relative contraindications that have been stated in this article are much like the previously published article.4 It is common practice for us to check the hemoglobin A1c level to ensure good blood glucose control. If the hemoglobin A1c level is higher than 7.5 percent, we do not offer reconstruction, and the patient is sent for medical management of their glucose. In addition, it is routine for us to check hemoglobin A1c levels on all patients with a body mass index greater than 35 kg/m2 to ensure that they are not diabetic. It is in this high–body mass index patient population that we have found prepectoral reconstruction to be very beneficial. Elimination of the muscle effect that compresses the implant leads to more projection of a given implant in the prepectoral space. One may think, why is prepectoral reconstruction functionally a better procedure for this difficult-to-treat group? Generally, high–body mass index patients do not have a strong core, and it is very clear when the patient tries to stand up as they use their upper body to control their posture when going from a lying or sitting position to upright. This activates the pectoralis major, among other muscle groups. On a regular basis, the patient relies on their upper body strength to function for their daily activities because of a
lack of their core strength, which can be an issue during the early postoperative days. The constant activation of the pectoralis major can lead to a shearing effect of the overlying mastectomy skin with the underlying muscle and acellular dermal matrix, which can lead to poor incorporation and seromas. When eliminating the pectoralis in this population, the shearing effect is much lower to possibly nonexistent, as there is no animation or movement of the muscle on top of the device with acellular dermal matrix extension. Therefore, we are seeing the same number of, if not fewer, complications in this high–body mass index group when performing immediate prepectoral expander-based reconstructions.7 We do think that, as more positive publications such as this further validate the safety and efficacy of prepectoral breast reconstruction, and as plastic surgeons continue to work more closely with breast surgeons (“as a team”), the quality of the mastectomies will continue to improve with regard to the mastectomy “footprint” and the “flap thickness” preserved. This will be a major step toward allowing plastic surgeons to further refine a reproducible, “templated” operative technique, removing more variables in these procedures. We also believe a more standardized and objective tissue perfusion assessment methodology will become standardized, because well-perfused flaps are critical for the success of any type of reconstruction and critical for the success of prepectoral reconstruction. It is important to understand that not every patient will have the same thickness of flaps, and possibly “thin flaps” is not an appropriate term for our understanding and for communicating with our peers. A mastectomy flap is going to vary from patient to patient and even from side to side in the same patient. A thin flap in a high– body mass index patient and a flap with the same thickness in a patient with a body mass index of 20 kg/m2 are going to behave very differently; therefore, it is important to assess the perfusion of each flap to ensure viability rather than determining whether a flap is thin or thick. The last issue that we would like to include is the cost justification of the regenerative materials in the larger surface area sizes necessary to carry out prepectoral breast reconstruction. Although longterm follow-up (in terms of years) will be necessary to evaluate the adequacy of the regeneratively created soft-tissue cover over prepectoral implants, undoubtedly, it is far easier and faster for a plastic surgeon to inset an acellular dermal matrix/device “construct” into an already prepared “mastectomy footprint space,” without the need for more invasive
445 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017 and time-consuming surgical muscle elevation. We have recently shown the cost effectiveness of the prepectoral as compared with dual-plane reconstruction, where a significantly shorter hospital stay was observed in the prepectoral group.5 Clearly, long-term studies are needed to understand how these flaps and implant-based reconstructions will behave. The value of the increased acellular dermal matrix will become even more clear once long-term studies show its use in prepectoral reconstruction as it relates to capsular contracture and lower pole soft-tissue stretch. Whether the early results of prepectoral reconstruction using the bioengineered breast concept will maintain the test of time remains to be seen. Evaluation of longer term outcomes will be necessary to ensure the adequacy of the “engineered” soft-tissue coverage. Allen Gabriel, M.D. Department of Plastic Surgery 505 NE, 87th Avenue, Suite 250 Vancouver, Wash. 98664 [email protected]
REFERENCES 1. Maxwell GP, Storm-Dickerson T, Whitworth P, Rubano C, Gabriel A. Advances in nipple-sparing mastectomy: Oncological safety and incision selection. Aesthet Surg J. 2011;31:310–319. 2. Maxwell GP, Gabriel A. Bioengineered breast: Concept, technique, and preliminary results. Plast Reconstr Surg. 2016;137:415–421. 3. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005;55:232–239. 4. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast reconstruction: Rationale, indications, and preliminary results. Plast Reconstr Surg. 2017;139:287–294. 5. Gabriel A, Sigalove S, Sigalove N, et al. Can surgical technique impact length of stay and post-operative outcomes in breast reconstruction? Plast Reconstr Surg Glob Open 2017;4:104–105. 6. Woo A, Harless C, Jacobson SR. Revisiting an old place: Single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction. Breast J. 2017. doi: 10.1111/tbj.12790. [Epub ahead of print]. 7. Gabriel A, Sigalove S, Maxwell GP, et al. Can closed incision negative pressure therapy impact postoperative outcomes in breast reconstruction? Plast Reconstr Surg Glob Open 2017;5:46–47.
446 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
T
he number of implant-based reconstructions continues to increase yearly, as breast reconstructions remain in the forefront of breast cancer surgery. The keystone to the improved quality of reconstructive outcomes has been the refinements in operative techniques, now practiced by oncologic breast surgeons, working closely with plastic surgeons, as they understand the importance of the preservation of oncologic sound mastectomy flaps.1 The advances in the availability of more cohesive and higher fill implants, scaffolds (acellular dermal matrices), and regenerative cells (processed fat with good quality) have revolutionized modern day breast reconstruction, and now we speak of “aesthetic breast reconstruction.”2 The dual-plane technique has been the standard of care in breast reconstruction and has been validated by many surgeons.3 Thus, to deviate from this gold standard, proof of new technique validation is needed, as one of the most recent advances has been the reintroduction of prepectoral reconstruction technique following mastectomy, where the pectoralis major is not manipulated or violated.4 This has led to easier recovery postoperatively and even improved aesthetic results because of the lack of animation deformity.5 Prepectoral breast reconstruction, a failed technique from the past, is now being resurrected by means of use of the regenerative constructs used in combination with advanced surgical devices and techniques. As this concept runs counter to our evolved current approach of the necessity for well-vascularized muscle cover over devices, we must document our outcomes and validate patient outcomes. Thus, we would like to congratulate the authors of this article for their contribution to this important topic. From the Department of Plastic Surgery, Loma Linda University Medical Center; and PeaceHealth Plastic Surgery. Received for publication May 12, 2017; accepted May 12, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003684
444
In this article, they have compared, prospectively, their standard “dual-plane” two-stage reconstruction technique series [using 6 × 16-cm AlloDerm (LifeCell Corp., Branchburg, N.J.)] to their prepectoral two-stage reconstruction (using 16 × 20-cm AlloDerm). Their results further confirm, as we and others have shown,4,6 that the feared complications of immediate reconstruction in prepectoral reconstruction are not different from those associated with the traditional dual-plane reconstruction. One early concern of surgeons and criticism of prepectoral reconstruction has been the fear of developing increased seromas, because of the large pieces of acellular dermal matrices that are used during this surgery. To avoid this feared complication in immediate reconstruction, we advocate meticulous pocket work for both dual-plane and prepectoral reconstructions. Lateral chest wall tissue is rotated from the posterior axillary line toward the anterior axillary line to further collapse the pocket. In the cephalad portion of the pocket, similar techniques are used to minimize the dead space as much as possible, especially in the prepectoral location, where we are directly placing the device and acellular dermal matrix. We agree with the authors that the technical placement of the acellular dermal matrix is critical, as one must ensure stability of the fold and the lower pole. This is achieved by the 3- to 4-cm overlap of the caudal portion of the acellular dermal matrix onto the chest wall to support the expander and future implant and allow for the gutter effect, enveloping the lower expander anteriorly and posteriorly.4 The weight load is redistributed throughout the acellular dermal matrix to the chest wall acellular dermal matrix. This further leads to creation of a crisp inframammary fold, as the implant and the expander will dictate the shape of the reconstructed breast. Disclosure: The authors are consultants for Allergan, Inc. No funds were received or utilized.
www.PRSJournal.com
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Discussion Biodimensional planning concepts remain a cornerstone in preoperative planning where the planned, probable final implant must be anticipated. This allows for an understanding of what the desired final width of the implant is going to be, regardless of shape (round versus anatomical) or even projection. Using this principle, an expander is then chosen that is at least 0.5 to 1 cm narrower. Whether performing a dual-plane or prepectoral reconstruction, all expanders are underfilled rather than overfilled and, at times, air (considered to be off-label) is used instead of saline. The underfilling of the expander is important, as this will help with the preparation of the new site for the placement of the future implant. This new site (pocket) should be snug for the future implant to allow for the implant to shape the breast long term. It is not unusual in our practice to place a 400-cc expander followed by an extra-projecting 800-cc implant in higher body mass index patients if this is the desire of the patient. Smaller expanders give the surgeon a great deal of flexibility when dealing with both anatomically shaped and round shaped implants. Thus, biodimensional planning and technical execution steps have stood the test of time and are as applicable to prepectoral breast reconstruction as to subpectoral or submuscular breast reconstruction. The relative contraindications that have been stated in this article are much like the previously published article.4 It is common practice for us to check the hemoglobin A1c level to ensure good blood glucose control. If the hemoglobin A1c level is higher than 7.5 percent, we do not offer reconstruction, and the patient is sent for medical management of their glucose. In addition, it is routine for us to check hemoglobin A1c levels on all patients with a body mass index greater than 35 kg/m2 to ensure that they are not diabetic. It is in this high–body mass index patient population that we have found prepectoral reconstruction to be very beneficial. Elimination of the muscle effect that compresses the implant leads to more projection of a given implant in the prepectoral space. One may think, why is prepectoral reconstruction functionally a better procedure for this difficult-to-treat group? Generally, high–body mass index patients do not have a strong core, and it is very clear when the patient tries to stand up as they use their upper body to control their posture when going from a lying or sitting position to upright. This activates the pectoralis major, among other muscle groups. On a regular basis, the patient relies on their upper body strength to function for their daily activities because of a
lack of their core strength, which can be an issue during the early postoperative days. The constant activation of the pectoralis major can lead to a shearing effect of the overlying mastectomy skin with the underlying muscle and acellular dermal matrix, which can lead to poor incorporation and seromas. When eliminating the pectoralis in this population, the shearing effect is much lower to possibly nonexistent, as there is no animation or movement of the muscle on top of the device with acellular dermal matrix extension. Therefore, we are seeing the same number of, if not fewer, complications in this high–body mass index group when performing immediate prepectoral expander-based reconstructions.7 We do think that, as more positive publications such as this further validate the safety and efficacy of prepectoral breast reconstruction, and as plastic surgeons continue to work more closely with breast surgeons (“as a team”), the quality of the mastectomies will continue to improve with regard to the mastectomy “footprint” and the “flap thickness” preserved. This will be a major step toward allowing plastic surgeons to further refine a reproducible, “templated” operative technique, removing more variables in these procedures. We also believe a more standardized and objective tissue perfusion assessment methodology will become standardized, because well-perfused flaps are critical for the success of any type of reconstruction and critical for the success of prepectoral reconstruction. It is important to understand that not every patient will have the same thickness of flaps, and possibly “thin flaps” is not an appropriate term for our understanding and for communicating with our peers. A mastectomy flap is going to vary from patient to patient and even from side to side in the same patient. A thin flap in a high– body mass index patient and a flap with the same thickness in a patient with a body mass index of 20 kg/m2 are going to behave very differently; therefore, it is important to assess the perfusion of each flap to ensure viability rather than determining whether a flap is thin or thick. The last issue that we would like to include is the cost justification of the regenerative materials in the larger surface area sizes necessary to carry out prepectoral breast reconstruction. Although longterm follow-up (in terms of years) will be necessary to evaluate the adequacy of the regeneratively created soft-tissue cover over prepectoral implants, undoubtedly, it is far easier and faster for a plastic surgeon to inset an acellular dermal matrix/device “construct” into an already prepared “mastectomy footprint space,” without the need for more invasive
445 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017 and time-consuming surgical muscle elevation. We have recently shown the cost effectiveness of the prepectoral as compared with dual-plane reconstruction, where a significantly shorter hospital stay was observed in the prepectoral group.5 Clearly, long-term studies are needed to understand how these flaps and implant-based reconstructions will behave. The value of the increased acellular dermal matrix will become even more clear once long-term studies show its use in prepectoral reconstruction as it relates to capsular contracture and lower pole soft-tissue stretch. Whether the early results of prepectoral reconstruction using the bioengineered breast concept will maintain the test of time remains to be seen. Evaluation of longer term outcomes will be necessary to ensure the adequacy of the “engineered” soft-tissue coverage. Allen Gabriel, M.D. Department of Plastic Surgery 505 NE, 87th Avenue, Suite 250 Vancouver, Wash. 98664 [email protected]
REFERENCES 1. Maxwell GP, Storm-Dickerson T, Whitworth P, Rubano C, Gabriel A. Advances in nipple-sparing mastectomy: Oncological safety and incision selection. Aesthet Surg J. 2011;31:310–319. 2. Maxwell GP, Gabriel A. Bioengineered breast: Concept, technique, and preliminary results. Plast Reconstr Surg. 2016;137:415–421. 3. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005;55:232–239. 4. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast reconstruction: Rationale, indications, and preliminary results. Plast Reconstr Surg. 2017;139:287–294. 5. Gabriel A, Sigalove S, Sigalove N, et al. Can surgical technique impact length of stay and post-operative outcomes in breast reconstruction? Plast Reconstr Surg Glob Open 2017;4:104–105. 6. Woo A, Harless C, Jacobson SR. Revisiting an old place: Single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction. Breast J. 2017. doi: 10.1111/tbj.12790. [Epub ahead of print]. 7. Gabriel A, Sigalove S, Maxwell GP, et al. Can closed incision negative pressure therapy impact postoperative outcomes in breast reconstruction? Plast Reconstr Surg Glob Open 2017;5:46–47.
446 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
