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      Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes

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          A paradigm shift in U.S. Breast reconstruction: increasing implant rates.

          Despite its benefits in body image, self-esteem, sexuality, and quality of life, historically fewer than 25 percent of patients undergo immediate breast reconstruction. After passage of the Women Health and Cancer Rights Act, studies failed to demonstrate changes in reconstructive rates. A recent single-year report suggests significant shifts in U.S. breast reconstruction patterns. The authors' goal was to assess long-term trends in rates and types of immediate reconstruction. A serial cross-sectional study of immediate breast reconstruction trends was performed using the Nationwide Inpatient Sample database from 1998 to 2008. Data on mastectomies, reconstructive method (autologous/implant), and sociodemographic/hospital predictors were obtained. Immediate breast reconstruction rates increased on average 5 percent per year, from 20.8 percent to 37.8 percent (p < 0.01). Autologous reconstruction rates were unchanged. Implant use increased by an average of 11 percent per year (p < 0.01), surpassing autologous methods as the leading reconstructive modality after 2002. The strongest predictors of implant use were procedures performed after 2002, bilateral mastectomies, patients operated on in Midwest/West regions, and Medicare recipients. In contrast to bilateral mastectomies, which increased by 17 percent per year (p < 0.01), unilateral mastectomies decreased by 2 percent per year (p < 0.01). Bilateral mastectomy defects had significantly higher reconstruction rates than unilateral counterparts (p < 0.01). The significant rise in immediate reconstruction rates in the United States correlates closely to a 203 percent expansion in implant use. Although the reason for the increase in implant use is multifactorial, changes in mastectomy patterns, such as increased use of bilateral mastectomies, are one important contributor.
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            Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy.

            Nipple-sparing mastectomy with immediate prosthetic reconstruction is routinely performed because of excellent aesthetic results and safe oncologic outcomes. Typically, subpectoral expanders are placed, but in select patients, this can lead to significant postoperative pain and animation deformity, caused by pectoralis major muscle disinsertion and stretch. Prepectoral reconstruction is a technique that eliminates dissection of the pectoralis major by placing the prosthesis completely above the muscle with complete acellular dermal matrix coverage.
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              Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.

              Complete submuscular tissue expander coverage affords the best protection against implant exposure but restricts lower pole expansion. Techniques using acellular dermis as a pectoralis muscle extension can allow for more rapid fill of the expander and better control of the inframammary fold. This study compares both techniques with regard to relevant outcomes. Results of 100 consecutive breast expander reconstructions performed by two surgeons between 2004 and 2007 were retrospectively reviewed. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of the expansion, and incidence and types of complications were analyzed. One hundred women underwent breast reconstruction with 172 expanders, in 50 using complete submuscular placement and in 50 using partial subpectoral placement with acellular dermis. The patient groups were similar in terms of demographic data. Mean number of fills to complete reconstruction was 4.31 in the submuscular group and 1.72 in the acellular dermis group (p = 0.0001). Mean intraoperative fill volume was 130 cc in the submuscular group, compared with 412 cc per expander in the acellular dermis group (p = 0.0001). Fisher's exact test demonstrated no significant difference in total complication rate between the two groups (14 percent versus 18 percent; p = 0.79). Acellular dermis allowed for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. The authors conclude that acellular dermis-assisted implant breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.
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                Author and article information

                Contributors
                (View ORCID Profile)
                Journal
                Journal of Plastic, Reconstructive & Aesthetic Surgery
                Journal of Plastic, Reconstructive & Aesthetic Surgery
                Elsevier BV
                17486815
                January 2023
                January 2023
                : 76
                : 76-87
                Article
                10.1016/j.bjps.2022.10.028
                36513014
                b6215a9e-4b24-4b39-ba0c-a9c79fa7fd31
                © 2023

                https://www.elsevier.com/tdm/userlicense/1.0/

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