TY - GEN
T1 - Direct-to-Implant Extracellular Matrix Hammock-based Breast Reconstruction; Subpectoral or Prepectoral?
AU - Lydia Dyrberg, Diana
PY - 2022/2/21
Y1 - 2022/2/21
N2 - Background: When performing direct-to-implant breast reconstruction (DIR) two methods are mainly used. The dual plane subpectoral implant pocket is well described and considered reliable due to a thick vascularized tissue cover protecting the implant. The submuscular plane is however associated with a risk of developing breast animation deformity (BAD), an unwillingly contraction of the pectoralis major muscle (PMM). This contraction can lead to muscle spasms, pain, and an aesthetically unattractive distortion of the nipple areolar complex (NAC), breast skin and/ormovement of the entire breast. The prepectoral plane is less invasive and has in combination with a biological or synthetic mesh shown outcomes comparable to reconstruction using subpectoral implant placement. The avoidance of muscular release might mitigate BAD, however new challenges may occur due to the thinner implant cover. The primary aim of this PhD project was to assess and compare the incidence and degree of BAD in women reconstructed by either subpectoral or prepectoral DIR.Material and methods: We conducted three separate studies investigating the incidence of BAD; A systematic literature review, a retrospective study, and a randomized clinical trial (RCT). The focus of the retrospective study and the RCT was to assess the incidence and degree of BAD between sub- and prepectorally reconstructed women utilizing our novel developed BAD grading scale: the Nipple, Surrounding skin, Entire breast (NSE) grading scale. The secondary outcome measures in the RCT included pain and complications, health-related quality of life (HRQOL) and patient satisfaction as well cosmetic evaluation. Results: The combined results showed that all patients reconstructed by subpectoral implant placement had some degree of BAD. Patients reconstructed by prepectoral implant placement were less prone to suffer from BAD, however the incidence of BAD was not totally mitigated. All the prepectorally reconstructed women which were assessed to have a degree of BAD, were graded with a mild degree of BAD. We found comparable complication rates between the sub- and prepectoral reconstructed groups. The level of postoperative pain was higher in the subpectoral group the first three postoperativedays, but there were no differences three months postoperative. Likewise, patients had a high HRQOL, and overall satisfaction assessed by the BREAST-Q. We found no differences betweengroups at any timepoint besides in the domain sexual well-being. Lastly, regardless of pocket plane, patients evaluated their cosmetic outcome equally high. When evaluation was done by the surgeon, we found a significant difference in cosmetic outcome at twelve months in favor of the prepectoral group.Conclusion: All patients reconstructed by the subpectoral implant placement showed some degree of BAD, whereas the majority of the prepectoral group did not reveal any degree of BAD. Ourresults furthermore demonstrated equal complications rates and comparable cosmetic outcomes between groups. Likewise, we found a high patient satisfaction showing no difference in HRQOLbetween groups. It seems BAD might not bother the patients as much as we have previously thought. From a clinical perspective, we believe the presented data allows us to offer both methodsfor DIR. Studies with larger cohorts and a longer follow-up are however warranted to fully determine the clinical significance of these findings. Furthermore, HRQOL was a secondary outcome measure in our study and a RCT utilizing the BREAST-Q to investigate HRQOL between sub- and prepectorally reconstructed groups as the primary outcome would be preferable.
AB - Background: When performing direct-to-implant breast reconstruction (DIR) two methods are mainly used. The dual plane subpectoral implant pocket is well described and considered reliable due to a thick vascularized tissue cover protecting the implant. The submuscular plane is however associated with a risk of developing breast animation deformity (BAD), an unwillingly contraction of the pectoralis major muscle (PMM). This contraction can lead to muscle spasms, pain, and an aesthetically unattractive distortion of the nipple areolar complex (NAC), breast skin and/ormovement of the entire breast. The prepectoral plane is less invasive and has in combination with a biological or synthetic mesh shown outcomes comparable to reconstruction using subpectoral implant placement. The avoidance of muscular release might mitigate BAD, however new challenges may occur due to the thinner implant cover. The primary aim of this PhD project was to assess and compare the incidence and degree of BAD in women reconstructed by either subpectoral or prepectoral DIR.Material and methods: We conducted three separate studies investigating the incidence of BAD; A systematic literature review, a retrospective study, and a randomized clinical trial (RCT). The focus of the retrospective study and the RCT was to assess the incidence and degree of BAD between sub- and prepectorally reconstructed women utilizing our novel developed BAD grading scale: the Nipple, Surrounding skin, Entire breast (NSE) grading scale. The secondary outcome measures in the RCT included pain and complications, health-related quality of life (HRQOL) and patient satisfaction as well cosmetic evaluation. Results: The combined results showed that all patients reconstructed by subpectoral implant placement had some degree of BAD. Patients reconstructed by prepectoral implant placement were less prone to suffer from BAD, however the incidence of BAD was not totally mitigated. All the prepectorally reconstructed women which were assessed to have a degree of BAD, were graded with a mild degree of BAD. We found comparable complication rates between the sub- and prepectoral reconstructed groups. The level of postoperative pain was higher in the subpectoral group the first three postoperativedays, but there were no differences three months postoperative. Likewise, patients had a high HRQOL, and overall satisfaction assessed by the BREAST-Q. We found no differences betweengroups at any timepoint besides in the domain sexual well-being. Lastly, regardless of pocket plane, patients evaluated their cosmetic outcome equally high. When evaluation was done by the surgeon, we found a significant difference in cosmetic outcome at twelve months in favor of the prepectoral group.Conclusion: All patients reconstructed by the subpectoral implant placement showed some degree of BAD, whereas the majority of the prepectoral group did not reveal any degree of BAD. Ourresults furthermore demonstrated equal complications rates and comparable cosmetic outcomes between groups. Likewise, we found a high patient satisfaction showing no difference in HRQOLbetween groups. It seems BAD might not bother the patients as much as we have previously thought. From a clinical perspective, we believe the presented data allows us to offer both methodsfor DIR. Studies with larger cohorts and a longer follow-up are however warranted to fully determine the clinical significance of these findings. Furthermore, HRQOL was a secondary outcome measure in our study and a RCT utilizing the BREAST-Q to investigate HRQOL between sub- and prepectorally reconstructed groups as the primary outcome would be preferable.
U2 - 10.21996/jdxh-3533
DO - 10.21996/jdxh-3533
M3 - Ph.D. thesis
PB - Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet
ER -