Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct-to-implant breast reconstruction

Abstract

Capsular contracture is a common adverse outcome following implant breast reconstruction, often associated with radiation treatment. The authors hypothesize that muscle fibrosis is the main contributor of breast reconstruction contracture after radiation. Retrospective chart review identified patients that underwent DTI reconstruction with pre-or post-operative breast irradiation. Signs of capsular contracture were assessed using clinic notes and independent graders reviewing two-dimensional images and anatomic landmarks. Capsular contracture rate was greater in the subpectoral vs. prepectoral group (n = 28, 51.8% vs. n = 12, 30.0%, p = 0.02). When compared to prepectoral DTI reconstruction in irradiated patients, subpectoral implant placement was nearly 4 times as likely to result in capsular contracture (p < 0.01). Rates of explantation, infection, tissue necrosis, and hematoma were comparable between groups. We also found that when subpectoral patients present with breast contracture, chemoparalysis of the muscle alone can resolve breast asymmetry, corroborating that muscle is a key contributor to breast contracture. As prepectoral breast reconstruction is gaining popularity, there have been questions regarding outcome following radiation treatment. This study suggest that prepectoral breast reconstruction is safe in an irradiated patient population, and in fact compares favorably with regard to breast contracture.

Conflict of interest statement

E.C.L. has consultant agreements with, but is explicitly not a speaker for, Musculoskeletal Transplant Foundation and Allergan Inc., manufacturers of FlexHD and AlloDerm, respectively. The other authors declares no conflict of interest.

Figures

Figure 1

Bilateral subpectoral DTI breast reconstruction. Patient images capture signs of capsular contracture following subpectoral implant placement and breast irradiation. Patient example (row 1) received pre-operative irradiation therapy on the right breast, where breast location remained consistent with no evidence of capsular contracture. Patient example (row 2) underwent PMRT on the right breast, with no evidence of breast mound elevation or implant deformity at 3-month follow-up post breast irradiation. Patient example (row 3) with image evidence of capsular contracture demonstrated progressive elevation of the left breast. Elevation of the nipple relative to the inframammary fold can be observed concurrent with apparent breast mound rigidity, which suggests capsular contracture. Similarly, the patient image (bottom row) demonstrated elevation of the nipple and breast mound on the irradiated side compared to the contralateral, non-irradiated side. Breast asymmetry and limited prosthesis deformity were observed following subpectoral DTI breast reconstruction when compared to the control (upper rows).

Figure 2

Bilateral prepectoral DTI breast reconstruction. Implant placement in the prepectoral space confers superior aesthetic result without significant prosthesis deformity or implant elevation, as evidenced by favorable nipple position relative to the inframammary fold and apparent breast symmetry. The top two patients did not exhibit signs of capsular contracture, but the bottom patient who had a tighter skin envelope on the right breast without nipple sparing, did show signs of capsular contracture. Importantly, skin dimpling or creasing is usually not observed in contracted prepectoral breast reconstruction, which suggests significant contribution by the pectoralis major muscle to breast mound deformity.

Figure 3

Change in implant positioning in subpectoral breast reconstruction following induction of generalized anesthesia. Relaxation of the pectoralis major muscle allows for descent of the implant from the superior margin of the mastectomy space and alignment along the inframammary fold, conferring a more natural breast shape and contour.

Figure 4

Change in breast form following post-mastectomy radiation therapy (PMRT). Panels (A–C) depict implant positioning relative to pectoralis major muscle in subpectoral and prepectoral breast reconstruction in patients who did not undergo post-mastectomy radiation therapy (PMRT). Skeletal muscle fibrosis (panels D–F) is associated with PMRT and often results in the following clinical signs after subpectoral breast reconstruction: (I) superolateral displacement of nipple areolar complex, (II) dimpling or creasing of the soft tissue envelope at the level of the pectoralis major muscle, (III) flattening of inferior pole projection, and (IV) axillary fold crease.