Prepectoral implant pocket conversion in breast reconstruction

The current article represents the first review about implant pocket conversion from a submuscular to a prepectoral plane, delineating its indications, surgical proficiency, postoperative complications, and functional and aesthetic outcomes. Ten articles in which 504 breasts were studied were deemed eligible for inclusion. The indications to perform plane conversion were animation deformity ( AD ), chronic annoyance, and implant malposition. Seven studies described complete or fond capsulectomy. The use of noncellular dermal matrices ( ADM ) was reported in all cases except for three studies. The mean follow-up was 10.64 months. There was resolution of AD in 100 % of cases. Three studies reported dispatch resolution of chronic annoyance. The overall complication pace was 12.102 % and capsular contracture ( CC ) was the most frequent complication. cosmetic revisions were reported in six studies ( 9.52 % ). The use of ADMs and fat transplant appeared to decrease the rate of subsequent CC formation and cosmetic revisions. While many authors have reported their experience in immediate prepectoral breast reconstruction ( BR ), plant pocket conversion from a submuscular to a prepectoral plane is less well described. The aim of this study is to provide a comprehensive review on plane conversion in implant-based BR, including the indications, surgical techniques, functional, and aesthetic results. The drive of this study is to provide a comprehensive examination reappraisal on plane conversion in implant-based BR, including the indications, surgical techniques, and functional and aesthetic results.

Although many authors have reported their experience with immediate prepectoral BR, 5, 6, 7, 8, 9, 10 – 11 delay prepectoral conversion is less describe. The prevalence of chronic pain after mastectomy and BR varies between 12 % and 49 %. 15 respective surgical and non-surgical elements may have affect on the growth of chronic pain such as injury on local nerves, axillary nodes dissection, radiation therapy, depression and anxiety. 17, 18. To date, there is however no consensus on whether the character and time of a BR can influence the development of post-mastectomy chronic pain. 17 historically, scoop conversion from submuscular to a prepectoral flat has not been accomplishable due to thin mastectomy skin envelopes. The handiness of ADMs and the use of fatten graft can make it possible to perform a pocket conversion in selected patients. The two main indications to pocket conversion are the appearance of muscular distortions ( animation disfigurement ( AD ) ) and the presence of chronic chest of drawers annoyance. AD can occur with any submuscular BR—regardless of the technique—and it has been observed in more than 50 % of patients. 14, 15, 16 choice of patients for immediate prepectoral implant placement has been well described. 11, 12, 13 however, these indications can besides be extended to patients with debatable submuscular reconstructions, where conversion to a prepectoral status may be beneficial. Implant-based breast reconstruction ( BR ) is the most common BR proficiency. Submuscular plant placement is considered standard exercise. 1, 2, 3, 4. – 5 Owing to the advances in mastectomy techniques including clamber and nipple spare procedures allied to intraoperative indocyanine green angiography to determine hide viability and the handiness of noncellular cuticular matrices ( ADMs ), prepectoral contiguous breast reconstruction ( IBR ) has gained more toleration. 6, 7 – 8 The chief advantages of prepectoral plant placement include the decrease of postoperative pain, the elimination of liveliness caused by dissection of the pectoral muscles, and the possibility to recreate a more natural breast determine with more age-appropriate ptosis. 9, 10 Extracted data included : type of study, sample distribution size ( issue of patients and breasts ), senesce, BMI, surgical reading ( AD, chronic pain, implant malposition ), inclusion and ejection criteria, surgical proficiency ( capsulectomy, use of ADMs, type of plant ), fat transplant ( before, during or after pouch conversion ), follow-up, outcomes ( AD and chronic pain resolution, patient ‘s satisfaction ), postoperative complications, and cosmetic revisions. ( one ) Review articles ; ( two ) event report ; ( three ) studies describing pocket conversion subsequent to aesthetic breast operation ; ( intravenous feeding ) articles reporting alone on surgical proficiency and not outcomes ; ( intravenous feeding ) studies that included fewer than eight breasts ; ( five ) non-referenced articles ; and ( six ) technical public opinion ( Level V ). ( one ) Studies describing implant pocket conversion from subpectoral to prepectoral airplane ; ( two ) studies describing pocket conversion subsequent to reconstructive summit surgery ; ( three ) studies that included more than eight breasts ; and ( four ) full text available in English. A literature search via PubMed, Medline, Google Scholar, and Cochrane database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis ( PRISMA ) guidelines 19 was performed using the comply engage terms : “ prepectoral pocket conversion ”, “ hypodermic pocket conversion ”, “ prepectoral plane conversion ”, “ hypodermic plane conversion ”, and “ prepectoral front reconstruction ” ( period : 2000–2020 ; last search on 19 April 2020 ). Two mugwump reviewers conducted a two-stage screen and data origin. different abstracts were examined to identify eligible papers. several reference lists of relevant articles were screened for far studies .


A full 239 articles were identified after having excluded duplicates. Two different reviewers examined all the records by titles and abstracts. twenty-three full-text articles were analyzed for eligibility. Ten articles published between 2014 and 2020 were considered eligible based on appropriateness, relevance, and actuality and were included in the systematic review (, PRISMA Guidelines ). All the studies were classified as LOE III based on the ASPS critical appraisal check sheet. 18 Among the ten selected articles, seven were retrospective studies 22, 23, 24, 25., 26, 28, 30 and three were prospective studies. 21, 27, 29 A entire of 504 breasts were included in the review and the sample size of each article ranged from 8 to 142 breasts. The mean age of patients was 53.013, while the mean BMI of patients was 27.421 ( range 19–48 ). The main indication to implant air pocket conversion was the appearance of AD. Chronic annoyance and implant malposition represented the other two indications mentioned respectively in six 24, 25, 27, 28, 29 and three articles. 23, 26, 27 In three studies the eligibility of patients was preoperatively evaluated using the pinch test. 22, 29, 30 In contingent, one study excluded patients with pinch test of less than 2 curium ; 22 one study excluded patients with apprehension test less than 1.5 curium at the upper pole of the breast ; 29 the last study excluded patients with touch screen less than 1 curium without handiness of fatten graft donor sites. 30 sixty-one patients undergo preoperative fat grafting. In one learn, former radiation sickness therapy, active voice smoke, poor skin perfusion, and uncontrolled diabetes were considered as excommunication criteria. 25 however, 41 patients included in the review undergo previous radiotherapy therapy. details preoperative affected role characteristics.

Table 1

Study Type of study and LOE N° of breasts Age BMI Indication Exclusion Criteria Prior RT Preoperative fat graft
Sbitany, 201421 P
8 AD None None
Hammond, 201522 R
19 54.5 AD Pinch test <2cm 8 pts
Schnars, 201623 R
54 27.3 AD No
Lenz, 201724 R
22 AD
Chronic pain
3 pts No
Gabriel, 201825 R
102 53.2 27.3
¼ obese
Chronic pain
Implant malposition
Previous RT
Poor skin quality/
Jones, 201926 R
142 55 28 AD None 21 pts No
29–82 19–48 AD
Chronic pain
55 49.8 26 AD
Chronic pain
Implant malposition
46/55 ADM)
2 groups:
prior fat graft
no prior fat graft:
20 50.8 AD
Chronic pain
Implant malposition
Pinch test
<1.5 cm at the upper pole
2 pts
Pinch test >1.5<3 cm at the upper pole and <1 cm at the lower pole
80 b 50.6 26 AD
Chronic pain
Pinch test <1 cm and no donor site available for fat grafting 10 pts 52.5%
Pinch test <1 cm

Open in a separate window All the studies described the universe of a fresh plane above the pectoral dashboard and the anchorage of the subscript margin of the pectoral major ( PM ) muscle to the later condensation or to the chest rampart ( ). A few authors recommended developing the plane between the overlying mastectomy skin flap and the underlie PM muscle, while the implant is placid in set in ordain to facilitate the dissection. Three authors performed an intraoperative mastectomy skin flap perfusion judgment using indocyanine park angiography. 23, 25, 27 Five studies described dispatch capsulectomy 21, 23, 28, 30 and two studies described partial capsulectomy 22, 25, 29 ( ). Hammond et alabama. 22 preserved the assign of the ejection seat under the PM and over the chest wall and Mangialardi et alabama. 29 described an anterior capsulectomy. All of the studies reported the habit of ADMs except for three studies in which a share of the sample undergo pocket conversion without ADMs ( 29 patients ). 24 – 28, 30 The majority of the authors reported anterior implant coverage, while three authors 28 – 30 described complete anterior and posterior coverage using one or two sheets of human-derived ADMs ( Alloderm ) or a single plane of bovine-derived ADM ( Braxon ; Decomed Srl ) ( ). Sbitany 21 used an ADM as a lower perch knoll and an upper punt spacer between the PM and the mastectomy hide roll. Gabriel et alabama. 25 described three different revision options : the first consisted of sum capsulectomy, removal of any preexist ADM, and complete anterior ADM coverage with 3 cm posterior gutter coverage ( partial ADM coverage ) ; the second consist of entire capsulectomy, removal of any preexisting ADM and dispatch anterior and later ADM coverage ( complete ADM coverage ) ; the third consisted of full capsulectomy, keeping the original lower pole ADM and adding an upper pole ADM with parachute sutures. Hammond performed fat graft at the same time as pocket conversion in football team patients. seven authors reported type ( round smooth silicone, anatomic texturized, cohesive gelatin ), size ( ranging from 220cc to 800cc ), and project of the implants. One learn described a average implant upsizing of 90.36cc. details the surgical technique used in each learn .

Table 2

Study Surgical technique Capsulectomy Implant ADM
Sbitany, 201421 capsulectomy prior to removal of the implant
PM dissection from the overlying mastectomy skin.
Anchorage of PM
Complete capsulectomy Alloderm
lower pole hammock and upper pole spacer
Hammond, 201522 PM dissection from the overlying mastectomy skin +
Fat graft
11 pt (57.9%) 115cc
deep to the dermis in the subcutaneous layer in the upper part of the breast, or between the skin and ADM in the lower part of the breast
Anchorage of PM
Partial capsulectomy preserving the capsule under the PM and over the chest wall. Smooth round silicone gel implant Size:
512cc (range 280–800)
Schnars, 201623 PM dissection from the overlying mastectomy skin
Anchorage of PM
Anterior coverage
Lenz, 201724 Once the superior flap is well elevated, the implant is removed and a complete open periprosthetic capsulectomy is performed. (alone 7/22; ADM 15/22) Complete capsulectomy 15/22
Complete coverage
Gabriel, 201825 Depending on the thickness and tightness of the skin flap, a direct-to-implant or two-stage tissue expander/implant reconstruction
Lower pole ADM was removed as much as possible to redrape the PM back to the chest wall.
In patients who had an LAD flap placed
at the lower pole during primary reconstruction, the PM was detached from the flap, which was
retained at the lower pole
Anterior and inferior capsulectomy Round silicone implant
Size: 603cc (400–800)
Alloderm 16 × 20 cm
Anterior coverage
Jones, 201926 PM dissection from the overlying mastectomy skin
Anchorage of PM
>FX or FF implant profile Alloderm 16 × 20
Anterior coverage
Bilezikian, 201927 Acellular dermal matrix drape and fluorescent imaging (ADFI) protocol Round, smooth
16 × 20 cm
Lenz, 201928 Once the superior flap is well elevated, the implant is removed and a complete open periprosthetic capsulectomy is performed. Complete capsulectomy Upsize
Smooth round cohesive or responsive silicone gel (Allergan)
15 ADM
7 no ADM
2 sheets Complete anterior and posterior coverage
Mangialardi 201929 The plane over the anterior capsule was undermined. The PM was then dissected from the overlying subcutaneous tissue recreating a new pocket. Anterior or subtotal capsulectomy Anatomic textured implants with a high or extra high projection
(range 265‐615 cc).
Total implant coverage
Holland, 202030 The inferior border of the pectoralis muscle is identified and incised, to gain access to the preexisting implant and capsule, both of which are removed. Complete capsulectomy when possible. In cases where ADM removal is deemed unsafe because of thin overlying skin, it is left in place and scored to assist
with recontouring.
Cohesive gel implants
588cc (220 −770)
Complete anterior, Partial posterior and inferior coverage

Open in a separate window average follow-up was 10.64 months ( range 9–19.2 months ). All the authors reported resolution of AD in 100 % of cases. Three studies reported complete and stable resolution of chronic pain as a immanent assessment. One learn reported improved crop of shoulder movement. Another discipline reported that even if chronic pain was not evaluated in the discipline, patients did not report annoyance during the follow-up menstruation. entirely one study mentioned the evaluation of preoperative and postoperative affected role ‘s satisfaction using the “ Breast Q questionnaire ” 31 describing an increase of 24 points in the “ satisfaction with front ” world and an increase of 20 points in the “ satisfaction with consequence ” knowledge domain. shows the postoperative outcomes of each study .

Table 3

Study Follow-up AD Chronic pain Pt’s satisfaction Cosmetic Revision Fat graft Capsulectomy Implant change
Sbitany, 201421 9 100% resolution
Hammond, 201522 13.8 100% resolution 16 pts (84.2) 6 2 (155 cc) 4 2
Schnars, 201623 100% resolution
Lenz, 201724 100% resolution 100% resolution 1 1 1
Gabriel, 201825 16,7 100% resolution Not evaluated although patients did not report pain during the follow-up period. Yes Yes
Jones, 201926 19.2 100% resolution Improved range of shoulder motion 26 25 (130 cc) 1 smaller implant size
Bilezikian, 201927 24 100% resolution 100% resolution None
Lenz, 201928 8.3 100% resolution 6 (21.4% of the group that did not undergo fat grafting, compared to 0% revisions performed on the group that had undergone fat grafting; p<0.01) 6 0 0
Mangialardi 201929 14.2 100% resolution 100% resolution BreastQ: – increase of 24 points “satisfaction with breast” domain – decrease of 20 points “satisfaction with outcome” (p < 0.001) None
Holland, 202030 15.2 100% resolution
cosmetic revision
7 asymmetric
9 pts Pre-conversion fat grafting and ADM cohorts were associated with fewer instances of cosmetic revision→ 4.8% VS 18.4%; (p = 0.08) and 6.2% VS 33.3%; (p = 0.01)

Open in a separate window The complicatedness rate was 12.102 % ( north = 61 ). Seromas were reported in 1.785 % of cases ( newton = 9 ; 2 patients undergo previous radiation therapy ), infection was reported in 4.96 % of cases ( normality = 25, 2 affected role undergo previous radiation therapy ), fond hide necrosis was reported in 1.19 % of patients ( north = 6 ; 1 patient undergo previous radiation sickness therapy ), wound dehiscence was reported in 0.793 % of cases ( newton = 4 ), postoperative hematoma was reported in 1.19 % of patients ( normality = 6 ), implant passing was described in 1.587 % of patients ( nitrogen = 8 ), and alone one affected role demonstrated a crimson breast syndrome ( 0.198 % ). Seroma attack required in-office drain aspiration in five cases, replacement of drain in one case, and any far interposition in two cases. In two cases, an implant removal was required. Infections were resolved by oral or intravenous antibiotic treatment in 10 cases and 9 cases, respectively ; a reoperation performing a flop of the implant ( plant removal and substitute ) was necessity in three cases ; the infection caused an implant loss in three patients. All cases of partial clamber necrosis and wind dehiscence were managed conservatively except for two patients in whom cutaneous necrosis required an implant removal. In lawsuit of hematoma, a surgical emptying was performed in two patients. The patient experiencing red breast syndrome was managed with conservative treatment and antibiotics. furthermore, 15 patients ( 2.976 % ) developed capsular contracture ( CC ) Baker grade III or IV during the follow-up period. Among them, nine patients underwent a pocket conversion without the use of ADM. Of the 29 cases who underwent a pocket conversion without ADM, 31.034 % developed a CC. Lenz et alabama. 24 reported that among the cohort of patients who underwent plant pocket change alone without ADM, 44.4 % of cases showed CC requiring reoperation compared to zero instances of CC when ADM was employed ( phosphorus < 0.01 ). similarly, Holland et aluminum. 30 reported a CC rate pair to 26.7 % and 1.5 % respectively in patients undergoing air pocket switch without or with ADM ( phosphorus < 0.01 ). furthermore, Lentz et aluminum. 24 suggested that preoperative adipose tissue grafting might decrease the incidence of CC. indeed, according to his study, patients who did not undergo preoperative fat grafting demonstrated a higher incidence of CC compared to patients who underwent preoperative fat transplant ( 4pts vanadium 0pts ; p = 0.11 ). similarly, in the study by Holland et alabama. 30, the cohort of patients undergoing pre-conversion fat transplant was associated with fewer instances of CC when compared to patients who did not undergo preemptive fat graft ( 0 vanadium 13.2 % ; p = 0.02 ).

reports complicatedness rates for each cogitation .

Table 4

Study Overall Complications Seroma Infection Hematoma Skin necrosis Wound dehiscence Red breast Sd Implant Loss CC
Sbitany, 201421 1 1
Hammond, 201522 5 1 4
Schnars, 201623
Lenz, 201724 2 1 1 (no ADM)
Gabriel, 201825 4 2 2 4 (1 RT) 1 4
Jones, 201926 13 3 (1 RT) 6 (1 RT) 1 1 1 1
Bilezikian, 201927
Lenz, 201928 13 8 1 1 5 (4 no ADM)
Mangialardi 201929 1 1
Holland, 202030 22 2 11 1 1 2 2 5 (4 no ADM)

Open in a separate window Six studies described secondary coil cosmetic revisions in 9.52 % of patients ( normality = 49 ). The cosmetic revisions included fat graft ( 12.01 % of patients ) due to minor implant edge visibility, rippling, or excavate, implant switch ( 0.83 % of patients ), and capsulectomy ( 1.39 % of patients ). One generator 30 reported that the manipulation of ADM was associated with fewer instances of asymmetry ( 15.4 % five 47 % ; p = 0.01 ) and the need for cosmetic rewrite operation ( 6.2 % volt 33.3 % ; p = 0.01 ). similarly, in the same study, pre-conversion fatten graft was related to a lower incidence of extra revision operations ( 4.8 % v 18.4 % ; p = 0.08 ). Likewise, Lenz et aluminum. 24 reported that 21.4 % of patients belonging to the group that did no undergo fat grafting undergo a rewrite cosmetic operating room compared to 0 % in the group that had undergo pre-conversion fatness transplant ( p < 0.01 ). illustrates the cosmetic revisions for each study .

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