Introduction

In 1951, Rice and Stickler described mastectomy with preservation of skin and nipple areola complex (NAC) for the first time for the treatment of a benign breast disease¹. Then, in 1962, Freeman introduced the term subcutaneous mastectomy, which was used until about 2003, when it became known as skin-sparing or NAC-sparing mastectomy². Immediate prepectoral implant-based breast reconstruction is becoming the standard of care following NAC-sparing mastectomy^3,4. The routine use of various types of mesh in association with the prepectoral technique has been described in several publications^5,6,7.

Adequate selection of patients with cutaneous tissue coverage > 2 cm results in good outcomes without adding these materials to the reconstructive process^8,9,10.

Prepectoral implant-based breast reconstruction is a technique that spares muscle and has recently been added to the armamentarium for breast reconstruction⁷.

With this technique, the implant is placed on the pectoralis major muscle in the subcutaneous plane, preserving the anatomical integrity of the muscle, eliminating animation deformity^5,6 and reducing pain^8,9,10. It also provides the reconstruction with a more natural appearance¹¹.

The aim of this study was to describe the surgical outcomes in a consecutive series of patients undergoing immediate prepectoral breast reconstruction with silicone implants.

Material and methods

We conducted a retrospective review of 52 immediate single-stage prepectoral breast reconstructions in 40 patients who underwent NAC- sparing mastectomy between March 2018 and December 2021. All the patients signed an informed consent form approved by the Committee on Ethics of the institution.

The patients were selected based on the findings of a preoperative digital mammogram. Patients were eligible if the thickness of the subcutaneous tissue in the upper breast flap was ≥ 2 cm. A single operator evaluated all mammograms, and measurements were obtained with OSIRIX® software (available at www.osirix-viewer.com). Breast tissue coverage measurements were reported in centimeters and millimeters. The patients were classified as type 1 to type 3 tissue coverage according to the thickness of the breast subcutaneous tissue: type 1: tissue coverage between 0 and 1 cm; type 2: between 1 and 2 cm; and type 3: > 2 cm (Fig. 1). The inclusion criteria were type 3 patients based on breast tissue coverage (subcutaneous tissue thickness of 2 cm or greater), small-to-moderate sized breasts (cup size A-B, 200-500g) stage I-II invasive carcinoma, carcinoma in situ (stage 0) and sarcoma, with grade 1 and 2 ptosis.

FIGURE 1 Breast tissue coverage classification 

The exclusion criteria were inflammatory carcinoma, skin involvement, abnormal nipple secretion, previous radiotherapy, hypertrophic and ptotic breasts, recent (last 12 months) peri- or subareolar surgery, and smoking habits (> 12 cigarettes/day). A survey was conducted among all patients to assess their level of satisfaction with the aesthetic outcomes rated as poor, fair, good, and excellent.

Results

A total of 40 patients were operated on with the technique described. Mean age was 52 years (range 30-76).

Twenty-eight patients underwent unilateral therapeutic mastectomy (23 for invasive carcinoma, 4 for ductal carcinoma in situ, and 1 for sarcoma), while 12 BRCA-positive patients underwent bilateral mastectomy to reduce risk. Sentinel lymph node biopsy was performed through a separate incision during the 40 therapeutic mastectomy procedures. Six patients with a positive lymph node biopsy underwent level I and II axillary lymph node dissection.

After mastectomy, the breast implant was placed in the prepectoral space via a 10-cm submammary incision (Fig. 2 a-b-c).

FIGURE 2 Result of prepectoral reconstruction with anatomical implants. A: Preoperative frontal view. B: Postoperative frontal view. C: Preoperative mammogram showing the subcutaneous tissue thickness. 

In all the cases, we used microtextured anatomical implants with a volume between 225 and 495 cm³. The implants were not covered by mesh in any of the cases.

A drain was placed in the mastectomy pocket and another one in the axilla after axillary lymph node dissection. Immediate contralateral breast symmetrization was not performed in any patient. Length of hospital stay was one day in 23 cases and two days in 17.

There were no major complications. Four breasts (7.7%) required surgical revision in the immediate postoperative period. After a mean follow- up period of 40 months, no animation deformities, implant displacement of rotation, tumor persistence or recurrence were observed. Three patients who received postmastectomy radiotherapy on the reconstructed breast developed Baker grade III or IV capsular contracture at one year.

The aesthetic results were categorized by the patients as excellent and good in 40 breasts (80.0%), fair in 8 breasts (12.0%) and poor in 4 breasts (8.0%).

Discussion

Implant-based breast reconstruction is a feasible technique with enduring results. Although submuscular reconstruction has been routinely performed^12,13,14, prepectoral implant-based reconstruction has recently been reported as the option to avoid muscle injury and its associated morbidity¹⁵.

Placing the implant in the prepectoral plane simplifies reconstruction and reduces pain^16,17,18, animation deformity, and functional impairment of the muscle^19,20. The feasibility and efficacy of prepectoral reconstruction has already been well documented by different authors^21,22,23.

Gabriel et al. did not find any association between the postoperative complications of this technique and body mass index, but they observed a relationship with smoking habits and diabetes²¹.

In a series of 52 prepectoral reconstructions conducted by Sigalove et al., the authors compared the outcomes between 34 individuals who underwent postmastectomy radiotherapy and 18 who did not. The results showed a good tolerance in the entire group, with no differences in short-term adverse effects or capsular contracture in any of the cases²².

In Argentina, Serrano et al. demonstrated good cosmetic results, low morbidity and high level of patient satisfaction in a series of 98 mastectomies using the same reconstructive technique²³.

Success with this technique relies on the careful selection of patients with cutaneous thickness > 2 cm and the implementation of meticulous surgical techniques^24,25.

In conclusion, the study demonstrated that prepectoral implant-based breast reconstruction, performed in a single stage immediately after mastectomy while preserving the areola-nipple complex in patients with fatty tissue coverage > 2 cm, is a safe and simple technique enabling immediate breast reconstruction without the disadvantages associated with subpectoral implant placement. This technique has high level of satisfaction with aesthetic results and without recurrence or tumor persistence.