TY - JOUR
AU - MD, Dennis C Hammond,
AB - “Take the muscle out of the equation.” The landscape for breast reconstruction has changed drastically over the past ten years for the reasons outline by the authors of this paper.1 Advances such as the greater acceptance of nipple sparing and skin sparing mastectomy strategies, fat grafting, the use of acellular dermal matrices (ADM), and a wider variety of breast expanders and implants has made the use of implant-based breast reconstruction a much more commonly applied approach. While the results of these implant-based reconstructions are frequently outstanding with a surprisingly low complication rate, the one drawback that has remained is related to breast animation secondary to the implant being placed under the pectoralis major muscle. For many patients, the resulting breast animation that occurs with contraction of the pectoralis major can be a significant drawback to what would otherwise be an excellent reconstructive result. Breast animation is also a well-recognized phenomenon in patients undergoing partial subpectoral pocket breast augmentation; however, due to the volume effect of the breast positioned on top of the muscle, the animation effect is variably blunted and becomes an acceptable compromise for most patients. However, in breast reconstruction, because the flaps are so thin, the animation effect becomes much more pronounced to the point of being problematic for many patients. This is the major reason that the concept of “prepectoral” implant placement has become a common operative strategy in both direct to implant as well as two stage immediate breast reconstruction. When viewed in this context, it is easy to understand how the surgical approach described by the authors could be so successful. To review, the authors selected for review a subset of patients who were experiencing problems related to their previous attempt at two stage implant-based breast reconstruction. Most notably, these patients were experiencing either problematic breast animation and/or pain. Further selection criteria included the exclusion of smokers, those patients with poor skin quality or perfusion, uncontrolled diabetes, and a history of prior irradiation, unless the reconstruction was supported by a latissimus flap. To treat these problems, a surgical strategy based upon implant removal coupled with suturing the pectoralis major back down to the chest wall was employed as the major component of an overall revisionary procedure. Perhaps most important, as a final component of the overall strategy, a pre-hydrated, perforated 16 by 20 cm piece of thick acellular dermal matrix was placed to support the reconstructive approach. This ADM was used predominantly as an anterior overlay covering the entire anterior portion of the implant space, leaving most of the posterior wall uncovered. Implant replacement with an appropriately chosen round or with anatomic devices was then performed to complete the procedure. Although it is not clearly stated in the paper, fat grafting was apparently applied later at secondary procedures as needed. It is interesting to note that in some cases a direct to implant approach was utilized at the time of muscle re-insertion, and in others a tissue expander was placed. The exact numbers for these two approaches are not reported. The results are based upon a retrospective review of the patient’s recovery. Breast animation was noted to be effectively resolved in all patients. A low 3.9% rate of complications was noted, and these were limited to seroma formation, wound dehiscence, and implant removal. Most notably, all the patients were graded as Baker grade 1 with regards to the development of capsular contracture. Overall, the results of this very successful operative strategy repeated the findings noted previously by the authors in a report of 350 prepectoral breast reconstructions.2 With this as a summary of the report, several points merit further comment. As expected, breast animation was resolved by placing the implants into a prepectoral position. However, it must be noted that in many patients there is still a subtle movement of the breast even with the prepectoral position because the capsule is attached to the muscle and moves slightly upward and outward with contraction of the pectoralis major. This can be seen with the patient example in the authors’ Figure 2 and is a phenomenon I have seen in my own patients. Beyond that, the major finding of this study relates to the complete absence of capsular contracture in the treated patient cohort. To be fair, the exclusion of certain patients who might be more prone to complications such as smokers and patients with a history of irradiation could somewhat skew the data in a positive direction, however, to report no instances of capsular contracture is remarkable. This has been a reported finding in other ADM studies, and this data set supports the conclusion that the use of an ADM can prevent capsular contracture from developing. This is a critically important finding as the cost of these materials is substantial and any recommendation as to their routine use must be backed by reliable data. To that end, it must be pointed out that this data represents a retrospective review. The precise way the presence of capsular contracture was assessed, and by who and when in the recovery process, is not noted. This has been the major problem in virtually all the capsular contracture literature reported to date. It is essentially a first-person account which is widely accepted as the least reliable form of communication regarding any topic. If the process of data collection had been specifically addressed by the authors, the strength of the paper and the ability of others to interpret its findings would have been significantly enhanced. Given this limitation, I have also personally noted that using ADM to line a pocket similar to what the authors describe has been an effective maneuver in treating capsular contracture. If the evaluation method used by the authors was incomplete and a few capsular contracture cases were missed, it is not my interpretation that these experienced surgeons would not be aware of it. There is something to be taken from this data, and that is using ADM in this fashion can be an effective adjunct in converting patients to a prepectoral implant location. Other technical points of importance relate to the management of the ADM. Any old capsule or leftover ADM was removed during the procedure to enhance the ability of the new ADM to incorporate into the freshly developed tissue interface. It is also noted that a perforated material was used that allowed flow of fluid between the anterior and posterior surfaces of the ADM. This enhances the ability of the material to incorporate as seroma formation between the ADM, and the skin flap is prevented. Because of this, it is necessary to use only one drain, which potentially decreases the chances for infection. As well, given the high cost of any ADM, the demonstration that there is no need to cover the posterior wall of the implant space against the ribs means slightly smaller pieces of ADM can be used as compared to the “total” front and back implant wrap technique that has been described by others. This can amount to a significant cost savings and a more efficient use of these materials, which it must be emphasized amounts to a tissue gift from donor families and must be treated with respect. In summary, this report provides encouraging data regarding patients undergoing implant-based breast reconstruction, and the authors are to be congratulated for their contribution. In my view, the future is represented by the concepts illustrated in the paper, namely, prepectoral implant placement, financially responsible pocket lining to prevent capsular contracture, soft tissue support via fat grafting to provide durable and soft mastectomy flaps, and improved implant designs to provide aesthetic shapes and long-lasting durability. As plastic surgeons, continuing to make advances in each of these areas, will be our charge going forward. Disclosures Dr Hammond is a medical advisor for Nova Plasma, and has a consulting agreement with Johnson and Johnson, Establishment Labs, and the Musculoskeletal Transplant Foundation. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Gabriel A, Sigalove S, Sigalove NMet al.   Prepectoral revision breast reconstruction for treatment of implant-associated animation deformity: a review of 102 reconstructions. Aesthet Surg J . 2018; 38( 5): 519– 526. 2. Sigalove S, Maxwell GP, Sigalove NMet al.   Prepectoral implant-based breast reconstruction: rationale, indications, and preliminary results. Plast Reconstr Surg . 2017; 139( 2): 287- 294. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
TI - Commentary on: Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions
JF - Aesthetic Surgery Journal
DO - 10.1093/asj/sjy036
DA - 2018-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/commentary-on-prepectoral-revision-breast-reconstruction-for-treatment-HPYkVyn0qs
SP - 527
EP - 528
VL - 38
IS - 5
DP - DeepDyve
ER -