I went to a bunch of talks about breast cancer reconstruction after mastectomy at our last ASPS meeting. This study is a review of the newer techniques in breast cancer reconstruction, where we are moving away from putting implants behind the muscle to putting implants in front of the muscle, but covering them in mesh to give more support and thickness. The study is “Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance” in Feb 2021 Plastic and Reconstructive Surgery Journal.
The mesh used can be ADM (acellular dermal matrix) or galaflex.
This retrospective study went all the way back to 1966. They found 58 articles, covering 3120 patients. Most of these studies were retrospective case series.
- Complication outcomes were variable, with no significant difference between groups with mesh and without with respect to hematoma, infection, or explantation rates.
- Capsular contracture rates were higher in no mesh cohorts.
- Seroma rates were higher in those with mesh.
They conclude we need more studies with a control group to understand the role of mesh, but it “suggests prepectoral breast reconstruction can be safely performed without surgical mesh.”
My thoughts?
I have been in plastic surgery long enough now to watch the pendulum swings of surgery. Use textured implants! Don’t use textured implants! Put it in front of the muscle! Don’t! Do!
I like the idea of prepectoral implant placement of implants if we can. That is where your natural breast sits. But in cancer patients for years now we place implants and expanders behind the pectoral muscle to try to decrease capsular contracture rates and to offer some padding to smooth the transitions and lumps and bumps of the underlying implant. But there are issues with going behind the muscle: the pectoral muscle thins with time, it may help push the implants down and lateral over time, and it can look funny when you work out. The issue with going in front of the muscle is the tissue after mastectomy is THIN. So you can see ripples and wrinkles. And there is a higher rate of capsular contracture. But mesh seems to help with a lot of these issues. And the new mesh on the market are significantly less expensive and seem to have good strength and support over time.
So the jury is out for me on this one. This is clearly a burgeoning topic. This study which is a retrospective study of a bunch of retrospective studies, some of which frankly are ancient, isn’t totally useful. The fact they didn’t see a big difference in complication rates and did see a lower capsular contracture rate is good.
I do think this is the future. Exactly who is a candidate, how it is done, what mesh is used, do we combine this with fat grafting, etc etc all need yet to be seen.