Introduction to “Prepectoral Breast Reconstruction”

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As the options for prosthetic breast reconstruction continue to expand, prepectoral reconstruction represents the most recent advancement. Although the concept of prepectoral breast reconstruction is not novel, recent technical and technological advancements have enabled plastic surgeons to revisit the prepectoral space and enhanced our ability to deliver excellent outcomes. A brief history of the evolution of device placement will clarify why prepectoral reconstruction has surged in popularity and why it may represent the next paradigm shift in prosthetic reconstruction.
During the 1970s, modified radical mastectomy was the standard. Attempts at prosthetic reconstruction were performed in the subcutaneous plane. Unfortunately, these reconstructions were marred by high 1-year complication rates that included capsular contracture in 56%, skin necrosis in 13.5%, and explantation in 28%.1 With the shift toward modified radical mastectomy, the subpectoral space became the preferred location and complication rates began to decline, especially with the advent of the Radovan tissue expander.2 Thus, since approximately 1980, total or partial muscle coverage of breast implants has been the gold standard for prosthetic breast reconstruction.
Over the past 10 years, a myriad of advancements in breast reconstruction have occurred that have further enhanced our ability to achieve excellent outcomes and include the use of acellular dermal matrices (ADMs), autologous fat grafting, as well as the use of cohesive and optimally filled prosthetic devices.3–5 In addition, breast surgeons have optimized mastectomy techniques for both skin and nipple-sparing mastectomy to preserve the vascularity and reduce skin flap necrosis. These advancements have led to the concept of the “bioengineered breast.”6 The premise behind this was that prosthetic breast reconstruction now closely mimicked augmentation mammaplasty. Although aesthetic outcomes were good to excellent in the majority of women following subpectoral placement of implants, the main drawback had to do with the sequelae of having an implant under the muscle, namely, animation with pectoral muscle contraction, widened cleavage plane due to the medial implant border along the medial origin of the pectoral major muscle, as well as the common patient complaint of tightness and discomfort in the chest.
The reintroduction of the subcutaneous or prepectoral location for breast implants occurred during this decade of enlightenment. Contrary to the 1970s, plastic surgeons are now able to manipulate and control many of the variables that were previously outside of our control such as fat grafting to further improve the thickness of the mastectomy skin flap, ADM for additional tissue support, to maintain the natural breast landmarks, and reduce the incidence of capsular contracture, as well as using optimally filled cohesive silicone gel breast implants to minimize rippling and wrinkling.
This supplement on Prepectoral Breast Reconstruction has been designed to provide the reader a complete understanding of the prepectoral technique and clarify why its use is increasing at such a high rate. The 7 articles were carefully selected and chosen to provide a full 360-degree overview of the topic. The authors are all nationally and internationally recognized experts who were selected based on their previous contributions and accomplishments regarding all aspects of breast reconstruction. The first article by Dr. Sbitany provides an overview of the topic and reviews patient selection, the importance of well-vascularized mastectomy skin flaps, working with breast surgeons, and reviews the different elements of success, namely ADM, perfusion assessment, and fat grafting. Dr. Gabriel discusses prepectoral reconstruction in the challenging patient. He reviews the technique in radiated patients as well as patients at the extremes of body mass index, both high and low. Another important consideration with prepectoral reconstruction is the assembly of the device and ADM. Dr.

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