Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: A new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy

Background: Nipple-sparing mastectomy (NSM) and implant-based breast reconstruction are increasingly replacing conventional mastectomy for risk-reducing purposes in high-risk patients as well as for therapeutic purposes in breast cancer patients. For implant-based breast reconstruction, generally, subpectoral implant placement with partial detachment of the pectoralis major muscle (PMM) is recommended. The advantage of a potentially better cosmetic result has to be balanced with the disadvantages, such as partial injury of the PMM with subsequent muscular deficit, breast animation, and postoperative pain. We hypothesize that prepectoral implant placement and complete coverage with a porcine acellular dermal matrix (ADM) may provide an alternative to subpectoral implant placement with an excellent cosmetic result, avoiding the disadvantages of subpectoral implant placement. Methods: In a total of 22 breasts in 13 patients (nine bilateral and four unilateral), NSM and immediate direct-to-implant breast reconstruction were performed with prepectoral implant placement. The implant was completely covered by a porcine ADM, which was sutured to the fascia of the PMM and the inframammary fold to keep the implant in place. Results: The cosmetic results were excellent and patients were fully satisfied at a median follow-up of 6 months. Breast animation and implant dislocation could not be observed. Implant rims were not visible, and capsular contractures grade III and IV could not be observed. The complications comprised minimal nipple necrosis in two patients and hemorrhage with evacuation in one patient. Conclusion: 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 for patients who prefer their PMM to be left intact. (C) 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.