The "Smile Mastopexy": A Novel Technique to Aesthetically Address the Excess Skin Envelope in Large, Ptotic Breasts While Preserving Nipple Areolar Complex During Prosthetic Breast Reconstruction

Prepectoral Two-Stage Implant-Based Breast Reconstruction with Poly-4-Hydroxybutyrate for Pocket Control without the Use of Acellular Dermal Matrix: A 4-Year Review

BACKGROUND

Absorbable mesh has been used to mitigate the potential drawbacks of acellular dermal matrix (ADM)-based breast reconstruction. Poly-4-hydroxybutyrate (P4HB) has been demonstrated to be a lower-cost, safe, and effective alternative to ADM in subpectoral breast reconstruction. In this study, the authors used P4HB for pocket control and implant support in immediate two-stage prepectoral breast reconstruction, examining nonintegration, capsular contracture, implant malposition, patient comorbidities, and risk factors.

METHODS

A retrospective review of a single surgeon's (K.M.) experience was performed over a 4-year span for patients who had undergone immediate two-stage prepectoral implant-based breast reconstruction with P4HB mesh. Complications (implant loss, rippling, capsular contracture, and malposition) and patient satisfaction were examined.

RESULTS

From 2018 to 2022, 105 patients underwent breast reconstruction using P4HB mesh on a total of 194 breasts. P4HB mesh integration was 97%. Sixteen breasts (8.2%) experienced minor complications, and 10.3% of devices required explantation, which was significantly higher in the irradiated group at 28.6% ( P < 0.01). Patients who were older, had a higher body mass index, were active smokers, or had an increased mastectomy specimen size were more likely to undergo explantation. The capsular contracture rate and overall lateral malposition rate were 1.0%. Visible rippling was present in 15.6% of breasts. There was no significant difference between smile mastopexy and inferolateral incision with regard to capsular contracture, lateral malposition, and rippling. Overall, patients demonstrated a high level of satisfaction. There were no significant predictors of capsular contracture, lateral malposition, or visible rippling.

CONCLUSIONS

The authors show the safety and efficacy of P4HB in two-stage prepectoral breast reconstruction. There appears to be equal, if not reduced, capsular contracture rates when compared with the published data on ADM. This represents a large cost reduction to both the patient and the health care system.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Modern Approaches to Implant-Based Breast Reconstruction

The modern approach to implant-based breast reconstruction encompasses an evolution in surgical techniques, patient selection, implant technology, and use of support materials. Successful outcomes are defined by teamwork throughout the ablative and reconstructive processes as well as appropriate and evidence-based utilization of modern material technologies. Patient education, focus on patient-reported outcomes, and informed and shared decision-making are the key to all steps of these procedures.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.