Surgery remains the cornerstone of the treatment of non-metastatic breast cancer but is also a major determinant of the quality of life (QoL) of breast cancer survivors, as is often associated - amongst other things - with significant body disfigurement. Breast reconstruction is widely used to improve the body image in these patients but it does come at a cost. In the immediate silicone-based reconstruction - the most common method of reconstruction worldwide - pectoralis major is traditionally lifted from the chest wall with transection of many of its insertions caudally and medially and the implant is placed underneath. This makes the procedure complex, causes pain, prolonged recovery time and animation deformities [Citation1].
The morbidity of pectoralis major after submuscular silicone-based reconstruction has been well described and is seen mainly as weakness, especially during shoulder adduction or retroflexion. This tends to persist for many months or years after surgery and is reflected in the DASH and Breast-Q scores reported by the patients. These observations are consistent with the abnormal dynamometric measurements of pectoralis major and even the muscle fiber degeneration seen on microscopic examination [Citation2–4]. In patients’ and surgeons’ minds the muscle morbidity is the “price to pay” for the reconstruction and is often seen as a necessary sacrifice.
The prepectoral implant placement has been recently introduced in an attempt to minimize exactly these side effects. The technique was made possible by the advent of ADMs, which are used to create a “pocket” anterior to pectoralis major, where the implant is placed in. The muscle is left untouched and the side effects originating by its manipulation are minimized [Citation5]. Caputo et al have previously described a modified technique of prepectoral placement of the implant in a “pocket” formed anteriorly by a de-epithelialized skin flap (caudally) and an ADM (cephalad) and by the untouched pectoralis major posteriorly [Citation6].
The value of the article published in this issue of J Invest Surg by the same team [Citation7] is the confirmation that the technique is not only technically feasible, but also has a favorable impact on the QoL, even on parameters that are often seen adversely affected in the submuscular reconstruction. Sixty-three patients (78 breasts) who were treated with mastectomy and immediate prepectoral silicone-based reconstruction with the use of ADM and de-epithelialized dermal flap, were studied. The EORTC QLQ-C30 and QLQ-BR23 questionnaires were administered preoperatively and 1 and 12 months postoperatively, while the BREAST-Q questionnaire was administered preoperatively and 12 months after surgery. After a slight drop in the first postoperative month, the majority of the studied parameters bounced back to the preoperative values or even exceeded them. This was the case not only with the more general parameters such as the global health status and the physical, role, emotional, cognitive, social and sexual functioning but also with these known to be specifically affected by the reconstruction procedure, like the pain and the breast and the arm symptoms. It is also worth noting that patients report very satisfied with their body image too.
Although there is no direct comparison of the QoL with other reconstruction techniques, it is safe to conclude that at least this proposed method is able to offer a high QoL fairly quickly after the surgical procedure.
This finding, however, comes as no surprise. It is consistent with reports where other variations of prepectoral reconstruction seem to have little adverse effect on parameters of the QoL that are often severely affected by the traditional submuscular reconstruction. In one, the QoL of patients undergoing prepectoral implant placement is not significantly different than the general female population in most of the parameters of SF-36 and BREAST-Q forms [Citation8]. In another, a prepectoral technique showed favorable results with regard to upper limb function when compared to the subpectoral method: there was less need for postoperative rehabilitation, less pain and – unsurprisingly – better postoperative quality of life [Citation9].
QoL is the core target of breast reconstruction and certainly more complex than simply a satisfactory body image. A reconstructive method that scores well across all QoL scales with minimal collateral damage – on top of achieving good cosmesis – is one step further in the holistic care of breast cancer.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
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- Patel AU, Day SJ, Pencek M, et al. Functional return after implant-based breast reconstruction: a prospective study of objective and patient-reported outcomes. J Plast Reconstr Aesthet Surg. 2020;73(5):850–855. doi:https://doi.org/10.1016/j.bjps.2019.11.038.
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- Domenici L, Caputo GG, Losco L, et al. Muscle-sparing skin-reducing breast reconstruction with pre-pectoral implants in breast cancer patients: long-term assessment of patients’ satisfaction and quality of life. J Invest Surg. 2021;20:1–7. [published on line ahead of print 2021 May 20] doi:https://doi.org/10.1080/08941939.2021.1923874.
- Spindler N, Ebel F, Briest S, Wallochny S, Langer S. Quality of life after bilateral risk-reducing mastectomy and simultaneous reconstruction using pre-pectoral silicone implants. Patient Prefer Adher. 2021;15:741–750. doi:https://doi.org/10.2147/PPA.S303208.
- Caputo GG, Zingaretti N, Kiprianidis I, et al. Quality of life and early functional evaluation in direct-to-implant breast reconstruction after mastectomy: a comparative study between prepectoral versus dual-plane reconstruction. Clin Breast Cancer. 2020; S1526-8209(20)30297-4. doi:https://doi.org/10.1016/j.clbc.2020.11.013.