From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital.
Plast Reconstr Surg. 2020 May;145(5):898e-908e. doi: 10.1097/PRS.0000000000006721.
Continued evolution of implant-based breast reconstruction involves immediate placement of the implant above the pectoralis muscle. The shift to prepectoral breast reconstruction is driven by goals of decreasing morbidity such as breast animation deformity, range-of-motion problems, and pain, and is made possible by improvements in mastectomy skin flap viability. To define clinical factors to guide patient selection for direct-to-implant prepectoral implant reconstruction, this study compares safety endpoints and risk factors between prepectoral and subpectoral direct-to-implant breast reconstruction cohorts. The authors hypothesized that prepectoral direct-to-implant breast reconstruction is a safe alternative to subpectoral direct-to-implant breast reconstruction.
Retrospective chart review identified patients who underwent prepectoral and subpectoral direct-to-implant breast reconstruction, performed by a team of five surgical oncologists and two plastic surgeons. Univariate analysis compared patient characteristics between cohorts. A penalized logistic regression model was constructed to identify relationships between postoperative complications and covariate risk factors.
A cohort of 114 prepectoral direct-to-implant patients was compared with 142 subpectoral direct-to-implant patients. The results of the penalized regression model demonstrated equivalence in safety metrics between prepectoral direct-to-implant and subpectoral direct-to-implant breast reconstruction, including seroma (p = 0.0883), cancer recurrence (p = 0.876), explantation (p = 0.992), capsular contracture (p = 0.158), mastectomy skin flap necrosis (p = 0.769), infection (p = 0.523), hematoma (p = 0.228), and revision (p = 0.122).
This study demonstrates that prepectoral direct-to-implant reconstruction is a safe alternative to subpectoral direct-to-implant reconstruction. Given the low morbidity and elimination of animation deformity, prepectoral direct-to-implant reconstruction should be considered when the mastectomy skin flap is robust.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
基于植入物的乳房再造的持续发展涉及将植入物置于胸肌上方的即刻放置。向胸肌前乳房重建的转变是由降低发病率的目标驱动的，例如乳房运动畸形、运动范围问题和疼痛，并且由于乳房切除术皮瓣存活率的提高而成为可能。为了定义指导患者选择直接植入物胸肌前植入物重建的临床因素，本研究比较了胸肌前和胸肌下直接植入物乳房重建队列的安全性终点和危险因素。作者假设胸肌前直接植入物乳房重建是胸肌下直接植入物乳房重建的安全替代方案。
回顾性图表审查确定了由五名外科肿瘤学家和两名整形外科医生团队进行的胸肌前和胸肌下直接植入物乳房重建的患者。单变量分析比较了队列之间的患者特征。构建了一个惩罚逻辑回归模型，以确定术后并发症与协变量危险因素之间的关系。
将 114 例胸肌前直接植入物患者的队列与 142 例胸肌下直接植入物患者的队列进行了比较。惩罚回归模型的结果表明，胸肌前直接植入物和胸肌下直接植入物乳房重建在安全性指标方面等效，包括血清肿（p = 0.0883）、癌症复发（p = 0.876）、取出（p = 0.992）、包膜挛缩（p = 0.158）、乳房切除术皮瓣坏死（p = 0.769）、感染（p = 0.523）、血肿（p = 0.228）和修复（p = 0.122）。
本研究表明，胸肌前直接植入物重建是胸肌下直接植入物重建的安全替代方案。鉴于发病率低且消除运动畸形，当乳房切除术皮瓣坚固时，应考虑胸肌前直接植入物重建。
临床问题/证据水平：治疗，III。
