First Reported Study on Prepectoral Implant-Based Breast Reconstruction with Poly-4-Hydroxybutyrate Mesh for Pocket Control and without the Use of Acellular Dermal Matrix
Prepectoral breast reconstruction has again become increasingly performed and reported upon. There have been concerns regarding capsular contracture, implant visibility, rippling, and malposition. The majority of recent prepectoral techniques within the literature are performed with a variable amount of Acellular Dermal Matrix (ADM) coverage without clear evidence-based guidelines regarding the indications and degrees of periprosthetic coverage with ADM. Poly-4-hydroxybutyrate mesh (P4HB mesh) has been shown to be beneficial for tissue reinforcement in the breast, such as in mastopexy. The purpose of this study was to assess our technique of prepectoral breast reconstruction with P4HB mesh for pocket control, mainly of the lateral breast border.
Methods/Technique:
A retrospective review of a single surgeon’s experience was performed. A search of the medical records was undertaken for 67 consecutive patients who had undergone prepectoral implant-based breast reconstruction in two stages. P4HB mesh was used for lateral pocket support; the mastectomy typically violates the lateral pocket and lateral malposition is common. The lateral pocket was first reestablished based on the location of the anterior axillary line. The skin flap was sutured to the lateral chest wall at the anterior axillary line, which was then reinforced with a 7.5 x 10 cm piece of the mesh. Biopsies of the capsule at the junction of normal and meshed-capsule were obtained during the first subsequent intraoperative evaluation of the pocket. The charts were reviewed for documentation of all complications including seroma, capsular contracture, malposition, implant visibility, infection, skin necrosis and explantation.
Results/Complications:
The surgeries were performed from 2018 through 2020. The retrospective review yielded 110 breasts in 67 patients who had undergone prepectoral two-stage implant-based breast reconstruction with P4HB mesh for lateral pocket support. 62 patients’ (105 breasts) reconstructions were performed in an immediate fashion, with the other 4 patients (6 breasts) were performed in a delayed immediate manner due to a high BRA score (Breast Reconstruction Risk Assessment Score, www.BRAscore.org). The mean age was 48 years (range: 28-73 years). The mean BMI was 29 kg/m2 (range: 20-43). The mean weight of the mastectomy specimen was 494 grams (range 104-1396g). The average follow up was 11 months (range: 4-24 months). Time to drain removal was on average 3 weeks after stage I surgery with 4 breasts (3.6%) developing seroma which required aspiration. We found 2 patients (3 breasts, 2.7%) with lateral malposition of the tissue expanders which were corrected with capsular flaps during the second stage. There was one case of non-integration of mesh which also happened to be in one of the two patients who had developed lateral malposition. One breast (0.9%) developed baker class II capsular contracture in the setting of postoperative radiation. 9 breasts (8 %) required tissue expander explantation for infection (4 breasts, 3.6%) or exposure (5 breasts, 4.5%) noting that the mesh had completely integrated in all. Of the explanted patients, 3 breasts had a history of previous radiation (2 had infection and one had exposure). Histologic assessment of 9 capsules with P4HB mesh were obtained for varying reasons at time intervals of 3 and 6 weeks (replacement of deflated TE’s) and 5, 6, 7, 10, 14, 15, and 22 months (during Stage II reconstruction), which demonstrated progressively less inflammatory response and ultimately normal tissue by 22 months, with full integration at all timelines.
Conclusion:
To our knowledge this is the first reported study for prepectoral implant-based breast reconstruction with Poly-4-hydroxybutyrate mesh for lateral pocket support without the use of ADM. The use of P4HB promises to be both safe and efficacious with much less cost to the healthcare system and with high patient and surgeon satisfaction. Long-term prospective multicenter studies of a larger patient population comparing no mesh to P4HB mesh to the ADM cohorts are necessary to establish future guidelines.