Prepectoral Breast Reconstruction: What you need to know

Recently, women undergoing mastectomy for treatment of breast cancer and interested in reconstruction are being presented with a new approach, Pre-pectoral breast reconstruction. What does it mean? How is it different? and who is a good candidate?

Let’s take a step back and explain what does a mastectomy involve? 

Simply put, the breast tissue and fat inside the breast are carved out and the skin is preserved. An implant is used to fill in this  space and restore the breast mound. Traditionally, implants were placed in a pocket created completely under the chest wall  muscle, also known as the pectoralis major muscle, or simply the pectoral muscle. Over the past decade, and with the advances in collagen matrices and acelluar dermal products, the pocket was converted to partial submuscular, where the upper half of the implant is covered by the muscle, and the lower half is covered by a sheet of acellular dermal matrix (treated human skin that has no cells). This sheet of skin stretches better than the muscle and allows the implant to stretch the lower curve of the breast. Despite the advantages of partial over full muscle coverage of theimplant, they both had the same disadvantage which is breast animation. When the patient activated the pectoral muscle, it squeezed the implant and elevated the skin and nipple over the implant creating an animation deformity. In addition to being cosmetically displeasing, many patients complain of tightness when the implants are placed under the muscle.Preprectoral Breast Reconstruction Surgery

What is Prepectoral Breast Reconstruction?

Pre-pectoral breast reconstruction is an implant-based reconstruction that places the breast implant above the pectoral (chest) muscle, and therefore eliminate both the animation problem and the tightness associated with placing the implant under the muscle. The implant is completely covered with a thick sheet of acellular dermal matrix (human skin) and is placed under the breast skin and above the muscle. The skin that is used to wrap the implant in the pre-pectoral technique is thicker than the one that was classically used for the partial coverage. One major advantage of placing the implant above the muscle (Pre-pectoral) is improved cleavage. When the implants are placed under the muscle, as the pectoral muscles contracted they pushed the implant sideways away from the midline and therefore negatively impacted cleavage.  In the Pre-pectoral technique, the implants are positioned to enhance cleavage without any force created by the muscle to push them to the side.
Prepectoral Breast Reconstruction Before and After

The main disadvantage of the prepectoral technique, is the fact that there is less soft tissue coverage over the implant, which makes the wrinkles of the implant more visible. This is usually solved with fat grafting and using implants that wrinkle less. Fat grafting involves injecting fat over the implant to thicken the soft tissue layer over the implant. Newer implants have been released to the market that have thicker gel and are over filled, and therefore wrinkle less.

Any patient can get a pre-pectoral reconstruction, but their skin after mastectomy has to be thick enough and has to have a good blood flow. The results have been very comparable to the classic partial muscle coverage technique with improved cleavage, less discomfort, and no animation.