Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.
Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA.
Ann Surg Oncol. 2021 Dec;28(13):9150-9158. doi: 10.1245/s10434-021-10085-z. Epub 2021 Aug 12.
BACKGROUND: Nipple-sparing mastectomy (NSM) offers improved aesthetics without compromising oncologic safety. Subpectoral breast reconstruction has long been standard practice, although prepectoral reconstruction has recently resurged in popularity. Due to this recent paradigm shift, studies comparing long-term outcomes by reconstructive plane are lacking. METHODS: A retrospective review was conducted on consecutive NSMs with implant-based reconstruction in either the prepectoral or subpectoral plane from 2014 to 2018. Patient demographics, implant specifications, and operative details were collected to evaluate primary outcomes of prosthetic failure and unplanned reoperations by reconstructive plane. Secondary outcomes included animation deformity, capsular contracture, rippling, plane change, and minor revisions, including fat grafting. Bivariate and multivariate analyses were performed to assess outcomes. RESULTS: Overall, 405 NSMs were performed on 228 women (subpectoral = 202, prepectoral = 203), with a mean follow-up of 2.1 years (standard deviation 1.1). During the study period (2014-2018), a shift from subpectoral to predominantly prepectoral mastectomies occurred in 2017. Prepectoral reconstructions were more often direct-to-implant (DTI) compared with subpectoral (73.9% vs. 33.2%, p < 0.001). Prepectoral reconstruction demonstrated significantly reduced prosthetic failure (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.14-0.65) and unplanned reoperations (OR 0.43, 95% CI 0.24-0.77) compared with subpectoral reconstruction after controlling for implant characteristics and other possible confounders. Prepectoral patients experienced decreased animation deformity overall (19.7% vs. 0.0%, p < 0.001), with plane changes seen in 10.6% of subpectoral reconstructions for animation deformity correction. Prepectoral patients experienced an increase in rippling (15.3% vs. 6.1%, p = 0.003) without a significant increase in fat grafting (subpectoral = 11.6% vs. prepectoral = 12.3%, p = 0.829). CONCLUSIONS: This single-institution experience compares late complications of prepectoral and subpectoral implant-based reconstruction following NSM. Prepectoral reconstruction can be safely performed with improved understanding of mastectomy planes, readily affords DTI reconstruction, and reduces animation deformity at the expense of rippling.
背景：保留乳头的乳房切除术（NSM）可改善美观效果，同时不影响肿瘤学安全性。胸肌下乳房重建一直是标准的手术方法，尽管胸肌前重建最近又重新流行起来。由于这种最近的范式转变，缺乏比较重建平面的长期结果的研究。
方法：对 2014 年至 2018 年间在胸肌前或胸肌下平面行植入物为基础的重建的连续 NSM 进行回顾性研究。收集患者的人口统计学、植入物规格和手术细节，以评估重建平面的假体失败和非计划再次手术的主要结果。次要结果包括运动畸形、包膜挛缩、波纹、平面改变和小的修正，包括脂肪移植。进行了双变量和多变量分析以评估结果。
结果：总体而言，228 名女性（胸肌下组=202 名，胸肌前组=203 名）共进行了 405 次 NSM，平均随访时间为 2.1 年（标准差 1.1）。在研究期间（2014-2018 年），2017 年胸肌下乳房切除术向胸肌前乳房切除术转变。与胸肌下重建相比，胸肌前重建更常直接植入（DTI）（73.9%比 33.2%，p<0.001）。在控制了植入物特征和其他可能的混杂因素后，与胸肌下重建相比，胸肌前重建显著降低了假体失败（优势比[OR]0.30，95%置信区间[CI]0.14-0.65）和非计划再次手术（OR 0.43，95%CI 0.24-0.77）的风险。与胸肌下重建相比，胸肌前重建患者的整体运动畸形减少（19.7%比 0.0%，p<0.001），其中 10.6%的胸肌下重建因运动畸形而需要改变平面。胸肌前重建患者的波纹增加（15.3%比 6.1%，p=0.003），而脂肪移植无明显增加（胸肌下=11.6%比胸肌前=12.3%，p=0.829）。
结论：本单中心经验比较了 NSM 后胸肌前和胸肌下植入物为基础的重建的晚期并发症。通过更好地了解乳房切除术平面，胸肌前重建可以安全进行，并且可以很好地进行 DTI 重建，同时以波纹为代价减少运动畸形。
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