Prepectoral versus subpectoral dual-plane immediate implant-based breast reconstruction after mastectomy in breast cancer patients: A prospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

XIAO Xiao ^1,2 , ZHU Zhongjian ¹ , FENG Yu ³ , ZHOU Jiao ⁴ , ZHOU Yun ² ,  DU Zhenggui ¹

1. Breast Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. Department of Breast and Thyroid Surgery, Chengdu Women’s and Children’s Central Hospital, Chengdu, 610031, P. R. China;
3. The Fourth People’s Hospital of Sichuan Province, Department of General Surgery, Chengdu, 610020, P. R. China;
4. Department of Thyroid and Breast Surgery, Ziyang Central Hospital, Ziyang, 641300, Sichuan, P. R. China;

Corresponding author：

DU Zhenggui, Email: docduzg@163.com

Keywords：

Breast cancer; mastectomy; breast reconstruction; prospective cohort study

DOI：

10.7507/1007-4848.202410010

Video：

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Objective To compare the satisfaction and safety of patients undergoing prepectoral breast reconstruction (PBR) versus subpectoral dual-plane breast reconstruction (SBR) with implants combined with mesh after open total mastectomy for breast cancer. Methods A prospective cohort study on clinical data of breast cancer patients who underwent open total mastectomy and received either PBR or SBR with implants and mesh for immediate breast reconstruction from June 2021 to October 2022 at West China Hospital of Sichuan University were performed. The pain scores on postoperative days 1, 3, 7, and 14, the use of analgesics within 14 days post-surgery, and the incidence of postoperative complications, breast satisfaction, and quality of life during follow-up periods were compared between the two groups. Results A total of 62 female patients were included, with 35 in the PBR group, having an average age of (39.6±6.5) years, and 27 in the SBR group, having an average age of (41.5±9.9) years. The pain scores of the SBR group on postoperative days 3 (P=0.032), 7 (P＜0.001), and 14 (P＜0.001) were significantly higher than those of the PBR group, and a higher proportion of patients in the SBR group used analgesics within 14 days post-surgery (P=0.001). The median follow-up time was 28.4 months for the PBR group and 34.9 months for the SBR group. There was no statistical difference in the overall (P=0.583), major (P=0.526), and minor (P=0.532) complication rates between the two groups during follow-up. One (2.9%) patient in the PBR group and two (7.4%) patients in the SBR group lost their implants (P=0.575). Four (14.8%) patients in each of the SBR group experienced movement deformities and chest muscle pain, whereas no patients in the PBR group had these issues (P=0.031). Encapsular contracture occurred in 5 (14.3%) patients in the PBR group and 11 (40.7%) patients in the SBR group (P=0.023). The incidences of ripple sign (25.7% vs. 3.7%, P=0.033) and implant contour visibility (40.0% vs. 11.1%, P=0.020) were significantly higher in the PBR group than those in the SBR group. At 24 months post-surgery, breast satisfaction scores were significantly higher in the PBR group [(67.9±13.1) points vs. (52.6±16.9) points, P=0.001]. The scores for cosmetic satisfaction [(70.7±13.4) points vs. (58.7±14.3) points, P=0.035] and chest function satisfaction [(70.7±13.4) points vs. (58.7±14.3) points, P=0.035] were higher in the PBR group. No local recurrence, distant metastasis, or deaths occurred in the PBR group during the follow-up period, while one patient of local recurrence and distant metastasis occurred in the SBR group, with no deaths. Conclusion Compared to SBR, PBR is more in line with the physiological and anatomical levels of the breast, effectively avoiding postoperative movement deformities and chest muscle pain, with a lower incidence of capsular contracture, and higher postoperative breast satisfaction and chest function satisfaction. It is a safe and feasible reconstruction method. For some specific patients, especially those with higher physical activity demands, it is a better reconstruction choice.

1.	Rocco N, Catanuto G. More evidence for implant-based breast reconstruction. Lancet Oncol, 2019, 20(2): 174-175.
2.	Zhang H, Li Y, Moran MS, et al. Predictive factors of nipple involvement in breast cancer: A systematic review and meta-analysis. Breast Cancer Res Treat, 2015, 151(2): 239-249.
3.	Zhang BL, Sivasubramaniam PG, Zhang Q, et al. Trends in radical surgical treatment methods for breast malignancies in China: A multicenter 10-year retrospective study. Oncologist, 2015, 20(9): 1036-1043.
4.	Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet, 1983, 1(8322): 459-462.
5.	Alderman AK, McMahon L, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg, 2003, 111(2): 695-703.
6.	Wilkins EG, Alderman AK. Breast reconstruction practices in north america: Current trends and future priorities. Semin Plast Surg, 2004, 18(2): 149-155.
7.	Eltahir Y, Werners LLCH, Dreise MM, et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: Comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg, 2013, 132(2): 201e-209e.
8.	Xu F, Lei C, Cao H, et al. Multi-center investigation of breast reconstruction after mastectomy from Chinese Society of Breast Surgery: A survey based on 31 tertiary hospitals (CSBrS-004). Chin J Cancer Res, 2021, 33(1): 33-41.
9.	Mennie JC, Mohanna PN, O'Donoghue JM, et al. National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study. Eur J Surg Oncol, 2017, 43(1): 52-61.
10.	Snyderman RK, Guthrie RH. Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg, 1971, 47(6): 565-567.
11.	Gruber RP, Kahn RA, Lash H, et al. Breast reconstruction following mastectomy: A comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg, 1981, 67(3): 312-317.
12.	Fan L, Strasser-Weippl K, Li JJ, et al. Breast cancer in China. Lancet Oncol, 2014, 15(7): e279-e289.
13.	Rinker B, Veneracion M, Walsh CP. Breast ptosis: Causes and cure. Ann Plast Surg, 2010, 64(5): 579-584.
14.	Rinker B, Veneracion M, Walsh CP. The effect of breastfeeding on breast aesthetics. Aesthet Surg J, 2008, 28(5): 534-537.
15.	Salzberg CA, Ashikari AY, Koch RM, et al. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg, 2011, 127(2): 514-524.
16.	Scheflan M, Colwell AS. Tissue reinforcement in implant-based breast reconstruction. Plast Reconstr Surg Glob Open, 2014, 2(8): e192.
17.	Bernini M, Calabrese C, Cecconi L, et al. Subcutaneous direct-to-implant breast reconstruction: Surgical, functional, and aesthetic results after long-term follow-up. Plast Reconstr Surg Glob Open, 2016, 3(12): e574.
18.	Vidya R, Masià J, Cawthorn S, et al. Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases. Breast J, 2017, 23(6): 670-676.
19.	Woo A, Harless C, Jacobson SR. Revisiting an old place: Single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction. Breast J, 2017, 23(5): 545-553.
20.	Weinzierl A, Schmauss D, Brucato D, et al. Implant-based breast reconstruction after mastectomy, from the subpectoral to the prepectoral approach: An evidence-based change of mind? J Clin Med, 2022, 11(11): 3079.
21.	Kappos EA, Schulz A, Regan MM, et al. Prepectoral versus subpectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02/ PREPEC): A pragmatic, multicentre, randomised, superiority trial. BMJ Open, 2021, 11(9): e045239.
22.	Israeli R. Complications of acellular dermal matrices in breast surgery. Plast Reconstr Surg, 2012, 130(5 Suppl 2): 159S-172S. 159S-172S.
23.	Tessler O, Reish RG, Maman DY, et al. Beyond biologics: Absorbable mesh as a low-cost, low-complication sling for implant-based breast reconstruction. Plast Reconstr Surg, 2014, 133(2): 90e-99e.
24.	Casella D, Bernini M, Bencini L, et al. TiLoop® Bra mesh used for immediate breast reconstruction: Comparison of retropectoral and subcutaneous implant placement in a prospective single-institution series. Eur J Plast Surg, 2014, 37(11): 599-604.
25.	Bowen ME, Mone MC, Buys SS, et al. Surgical outcomes for mastectomy patients receiving neoadjuvant chemotherapy: A propensity-matched analysis. Ann Surg, 2017, 265(3): 448-456.
26.	Xiao X, Long Q, Li H. Clinical application of immediate prepectoral implant-based breast reconstruction with TiLoop Bra after skin-sparing or nipple-areola-complex-sparing mastectomy for breast cancer patients. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(4): 538-545.
27.	Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg, 2009, 124(2): 345-353.
28.	Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
29.	Spear SL, Baker JL, Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1123.
30.	Safran T, Al-Badarin F, Al-Halabi B, et al. Aesthetic limitations in direct-to-implant prepectoral breast reconstruction. Plast Reconstr Surg, 2022, 150(1): 22e-31e.
31.	Handel N, Cordray T, Gutierrez J, et al. A long-term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg, 2006, 117(3): 757-767.
32.	Ng EI, Quah GS, Graham S, et al. Immediate prepectoral implant reconstruction using TiLOOP Bra Pocket results in improved patient satisfaction over dual plane reconstruction. ANZ J Surg, 2021, 91(4): 701-707.
33.	Dyrberg DL, Bille C, Koudahl V, et al. Evaluation of breast animation deformity following pre- and subpectoral direct-to-implant breast reconstruction: A randomized controlled trial. Arch Plast Surg, 2022, 49(5): 587-595.
34.	Liu J, Chen C, Chen H, et al. Patient-reported outcomes and complication profiles of implant-based breast reconstruction in patients with postmastectomy radiation therapy. Ann Plast Surg, 2024, 93(1): 22-29.
35.	Ostapenko E, Nixdorf L, Devyatko Y, et al. The impact of adjuvant radiotherapy on immediate prepectoral implant-based breast reconstruction. Aesthetic Plast Surg, 2024, 48(13): 2432-2438.
36.	Araco A, Caruso R, Araco F, et al. Capsular contractures: A systematic review. Plast Reconstr Surg, 2009, 124(6): 1808-1819.
37.	Reitsamer R, Peintinger F. Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: A new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg, 2015, 68(2): 162-167.

1. Rocco N, Catanuto G. More evidence for implant-based breast reconstruction. Lancet Oncol, 2019, 20(2): 174-175.
2. Zhang H, Li Y, Moran MS, et al. Predictive factors of nipple involvement in breast cancer: A systematic review and meta-analysis. Breast Cancer Res Treat, 2015, 151(2): 239-249.
3. Zhang BL, Sivasubramaniam PG, Zhang Q, et al. Trends in radical surgical treatment methods for breast malignancies in China: A multicenter 10-year retrospective study. Oncologist, 2015, 20(9): 1036-1043.
4. Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet, 1983, 1(8322): 459-462.
5. Alderman AK, McMahon L, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg, 2003, 111(2): 695-703.
6. Wilkins EG, Alderman AK. Breast reconstruction practices in north america: Current trends and future priorities. Semin Plast Surg, 2004, 18(2): 149-155.
7. Eltahir Y, Werners LLCH, Dreise MM, et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: Comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg, 2013, 132(2): 201e-209e.
8. Xu F, Lei C, Cao H, et al. Multi-center investigation of breast reconstruction after mastectomy from Chinese Society of Breast Surgery: A survey based on 31 tertiary hospitals (CSBrS-004). Chin J Cancer Res, 2021, 33(1): 33-41.
9. Mennie JC, Mohanna PN, O'Donoghue JM, et al. National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study. Eur J Surg Oncol, 2017, 43(1): 52-61.
10. Snyderman RK, Guthrie RH. Reconstruction of the female breast following radical mastectomy. Plast Reconstr Surg, 1971, 47(6): 565-567.
11. Gruber RP, Kahn RA, Lash H, et al. Breast reconstruction following mastectomy: A comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg, 1981, 67(3): 312-317.
12. Fan L, Strasser-Weippl K, Li JJ, et al. Breast cancer in China. Lancet Oncol, 2014, 15(7): e279-e289.
13. Rinker B, Veneracion M, Walsh CP. Breast ptosis: Causes and cure. Ann Plast Surg, 2010, 64(5): 579-584.
14. Rinker B, Veneracion M, Walsh CP. The effect of breastfeeding on breast aesthetics. Aesthet Surg J, 2008, 28(5): 534-537.
15. Salzberg CA, Ashikari AY, Koch RM, et al. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg, 2011, 127(2): 514-524.
16. Scheflan M, Colwell AS. Tissue reinforcement in implant-based breast reconstruction. Plast Reconstr Surg Glob Open, 2014, 2(8): e192.
17. Bernini M, Calabrese C, Cecconi L, et al. Subcutaneous direct-to-implant breast reconstruction: Surgical, functional, and aesthetic results after long-term follow-up. Plast Reconstr Surg Glob Open, 2016, 3(12): e574.
18. Vidya R, Masià J, Cawthorn S, et al. Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases. Breast J, 2017, 23(6): 670-676.
19. Woo A, Harless C, Jacobson SR. Revisiting an old place: Single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction. Breast J, 2017, 23(5): 545-553.
20. Weinzierl A, Schmauss D, Brucato D, et al. Implant-based breast reconstruction after mastectomy, from the subpectoral to the prepectoral approach: An evidence-based change of mind? J Clin Med, 2022, 11(11): 3079.
21. Kappos EA, Schulz A, Regan MM, et al. Prepectoral versus subpectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02/ PREPEC): A pragmatic, multicentre, randomised, superiority trial. BMJ Open, 2021, 11(9): e045239.
22. Israeli R. Complications of acellular dermal matrices in breast surgery. Plast Reconstr Surg, 2012, 130(5 Suppl 2): 159S-172S. 159S-172S.
23. Tessler O, Reish RG, Maman DY, et al. Beyond biologics: Absorbable mesh as a low-cost, low-complication sling for implant-based breast reconstruction. Plast Reconstr Surg, 2014, 133(2): 90e-99e.
24. Casella D, Bernini M, Bencini L, et al. TiLoop® Bra mesh used for immediate breast reconstruction: Comparison of retropectoral and subcutaneous implant placement in a prospective single-institution series. Eur J Plast Surg, 2014, 37(11): 599-604.
25. Bowen ME, Mone MC, Buys SS, et al. Surgical outcomes for mastectomy patients receiving neoadjuvant chemotherapy: A propensity-matched analysis. Ann Surg, 2017, 265(3): 448-456.
26. Xiao X, Long Q, Li H. Clinical application of immediate prepectoral implant-based breast reconstruction with TiLoop Bra after skin-sparing or nipple-areola-complex-sparing mastectomy for breast cancer patients. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(4): 538-545.
27. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg, 2009, 124(2): 345-353.
28. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
29. Spear SL, Baker JL, Jr. Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg, 1995, 96(5): 1119-1123.
30. Safran T, Al-Badarin F, Al-Halabi B, et al. Aesthetic limitations in direct-to-implant prepectoral breast reconstruction. Plast Reconstr Surg, 2022, 150(1): 22e-31e.
31. Handel N, Cordray T, Gutierrez J, et al. A long-term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg, 2006, 117(3): 757-767.
32. Ng EI, Quah GS, Graham S, et al. Immediate prepectoral implant reconstruction using TiLOOP Bra Pocket results in improved patient satisfaction over dual plane reconstruction. ANZ J Surg, 2021, 91(4): 701-707.
33. Dyrberg DL, Bille C, Koudahl V, et al. Evaluation of breast animation deformity following pre- and subpectoral direct-to-implant breast reconstruction: A randomized controlled trial. Arch Plast Surg, 2022, 49(5): 587-595.
34. Liu J, Chen C, Chen H, et al. Patient-reported outcomes and complication profiles of implant-based breast reconstruction in patients with postmastectomy radiation therapy. Ann Plast Surg, 2024, 93(1): 22-29.
35. Ostapenko E, Nixdorf L, Devyatko Y, et al. The impact of adjuvant radiotherapy on immediate prepectoral implant-based breast reconstruction. Aesthetic Plast Surg, 2024, 48(13): 2432-2438.
36. Araco A, Caruso R, Araco F, et al. Capsular contractures: A systematic review. Plast Reconstr Surg, 2009, 124(6): 1808-1819.
37. Reitsamer R, Peintinger F. Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: A new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg, 2015, 68(2): 162-167.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

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