Nipple-sparing mastectomy and direct-to-implant breast reconstruction with prepectoral implant placement

Nipple-sparing mastectomy (NSM) is replacing the conventional mastectomy in most patients. Immediate breast reconstruction is an integral part of this procedure. For the implant-based breast reconstruction generally the subpectoral implant placement is recommended. The advantage of a potentially better cosmetic result has to be balanced with the disadvantages, such as partial detachment of the pectoralis major muscle (PMM) with subsequent muscular deficit, breast animation and postoperative pain. Prepectoral implant placement and complete coverage with a porcine acellular dermal matrix (ADM) may provide an alternative with an excellent cosmetic result avoiding the disadvantages of the subpectoral implant placement.

In a total of 70 breasts in 49 patients NSM and direct-to-implant breast reconstruction with prepectoral implant placement was performed. The implant was completely covered by a porcine ADM, which was sutured to the fascia of the PMM and to the inframmary fold to keep the implant in place.

Cosmetic results were excellent at a median follow-up of 16 months. Breast animation and implant displacement could not be observed. Implant rims were visible and palpable in the upper poles of 3 very skinny patients and visible rippling could be observed in 2 patients. Capsular contractures could not be observed, not either in 12 patients treated with radiotherapy. Complications comprised minimal nipple necrosis without further intervention in 4 breasts and hematoma with evacuation in 5 breasts.

Prepectoral implant placement and complete coverage with porcine ADM represents a novel approach and a feasible alternative to subpectoral implant placement after NSM and implant-based breast reconstruction.