As a nurse in surgical oncology, I have worked with patients recovering from mastectomies who have had to make decisions about whether to have breast reconstruction surgery. There are a variety of options to choose from.

A study published in the journal Plastic and Reconstructive Surgery, conducted by Hani Sbitany, MD, associate professor of plastic and reconstructive surgery at the University of California, San Francisco, described a surgical procedure, called prepectoral breast reconstruction, that was used among patients who had mastectomies and radiation therapy following their breast cancer diagnosis.¹

This procedure is an option that oncology nurses can familiarize themselves with for their existing or future patients with breast cancer. It has been my experience that non-OR nurses are not always aware of surgical techniques that have changed. However, increasing knowledge of different surgical procedures will benefit patients in the long run.

Benefits of Using Prepectoral Implants

Prepectoral breast reconstruction is a procedure in which implants are positioned on top of the muscle and supported by a biological mesh product called an acellular dermal matrix. Patients benefit from this procedure in several ways: There is less pain compared with under-the-muscle procedures; it eliminates animation deformity; and it results in higher patient satisfaction, according to the study. In addition, this procedure can preserve the pectoralis major muscle and chest wall function.¹

Selection of Patients

Patients with existing submuscular breast implants who had their surgeries done 5 to 15 years ago may be eligible for this procedure.

In addition, by “routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting,” women at different stages of postoperative care can have this surgery.¹ This includes those opting to have reconstruction right after mastectomy as well as those having the surgery later, as part of a 2-stage tissue expander-based reconstruction.¹

The surgeon must consider several factors before proceeding with prepectoral breast reconstruction. Specific criteria for not proceeding with this surgery involves a malignancy that “invades the chest wall or comes to within 0.5 cm of the pectoralis major muscle.”¹ Patients with this type of tumor have potential for a larger risk of recurrence.¹ Also, it is unsuitable for candidates with inflammatory breast cancer, stage IV disease, and strong axillary metastasis.¹

Diabetes with poor control, as well as being classified as obese, with a BMI of more than 35 is deemed a contraindication to this surgery. Smoking, either currently or in the recent past, are also terms for exclusion as it concerns the vascular status of the patient.

Downsides

Circulation that is not of optimal quality sets the stage for “poor soft-tissue quality, thus increasing the risk of skin flap necrosis and extrusion or infection of the prosthesis.”¹ Women who have previously undergone radiation to the affected breast are at risk of wound problems such as dehiscence with this technique.¹ And lastly, infection is another concern.

In addition to medical concerns, the mesh is expensive, and insurance may not cover it. It has been suggested that this new acellular dermal matrix may raise the price to double that of traditional reconstructive surgery.²

To further evaluate this procedure, Sbitany, who also consults for Allergan—the producer of the mesh–has been conducting a study (to be published in the journal Plastic and Reconstructive Surgery in early 2019) using feedback from patients who have chosen to receive prepectoral implants.

References

• Hani S. Important considerations for performing prepectoral breast reconstruction. Plast Reconstr Surg. 2017;140:7S—13S. doi:10.1097/PRS.0000000000004045.
• Rabin RC. New approach to breast reconstruction may reduce pain and weakness for some. The New York Times. nytimes.com/2018/09/17/well/live/breast-reconstruction-implants-muscle.html. Published September 17, 2018. Accessed November 29, 2018.