Prepectoral implant placement and complete coverage with acellular dermal matrix (ADM) for direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM)

NSMs replace conventional mastectomies in most patients. Immediate breast reconstruction is an integral part of this procedure. For the implant-based breast reconstruction generally the subpectoral implant placement is recommended. The theoretic advantage of a better cosmetic result has to be outweighed with the disadvantages (partial detachment of the pectoralis major muscle (PMM) with subsequent muscular deficit, breast animation and postoperative pain). Prepectoral implant placement and complete coverage with an ADM may provide an alternative with an excellent cosmetic result avoiding the disadvantages of the subpectoral implant placement.

In a total of 121 breasts in 84 patients NSM and DTI-breast reconstruction with prepectoral implant placement was performed. The implant was completely covered by a porcine ADM, which was sutured to the fascia of the PMM and the superficial thoracic fascia thoracica superficialis and to the inframmary fold to keep the implant in place.

Cosmetic results were excellent at a median follow-up of 24 months. Breast animation and implant dislocation could not be observed. Implant rims were visible and palpable in the upper poles of 5 very skinny patients and visible rippling could be observed in 6 patients. Major complications comprised skin necrosis with implant loss in one breast and hemorrhage with evacuation in 7 breasts, minor complications comprised minimal nipple necrosis without further intervention in 5 breasts.

Prepectoral implant placement and complete coverage with porcine ADM after NSM represents a novel approach and a feasible alternative to subpectoral implant placement for patients preferring their pectoralis major muscle to be left intact.