Subpectoral vs. Prepectoral Breast Reconstruction Surgery

Implant-based breast reconstruction remains the most common form of mastectomy reconstruction after breast cancer. Breast implant surgery represents approximately two-thirds of all breast reconstructions. The remaining reconstructions are autologous or “flap” reconstruction, which uses tissue from your own body to reconstruct the breast.

Subpectoral Breast Implant Surgery

While new technology allows some women to receive implants during the mastectomy procedure (called “direct-to-implant”), the typical subpectoral implant-based reconstruction uses a two-stage approach. First, a tissue expander is placed at the time of the mastectomy. After expanding to the desired volume, the patient is returned to the operating room for exchange of the tissue expander for the final breast implant, almost always a silicone gel implant. There are several issues with this technique:

  • It involves placing the implant under the pectoralis major muscle, which can be painful.
  • Because it is under the muscle there is what is called “animation of the implant”. This means that as the muscle contracts, the implant tends to move upwards, and then back again when the muscle relaxes.

As a result of these main issues with subpectoral implants, prepectoral placement of the implant may be an alternative.

How Prepectoral Breast Reconstruction Works

With prepectoral implants, either two-staged with a tissue expander or direct-to-implant, the implant is placed above the muscle. Since there is no muscle coverage to protect the implant, the implant is wrapped in an acellular dermal matrix (ADM). ADM is made from the collagen layer of donated human skin and helps create an internal supportive and flexible structure to hold the implant in place. Then, skin from the area underneath the breast, where the breast meets the chest (called the “inframammary fold”), is used to cover the implant.

Like subpectoral reconstruction, there are also issues with the prepectoral reconstruction technique:

  • The mastectomy flaps, the skin that will cover the new implant, must be thick enough to provide good blood flow to the skin.
  • If there is an issue with blood flow or circulation (also called “vascularity”) to the skin, the implant could be threatened as there is no muscle coverage
  • If the mastectomy flaps have good blood flow, but are thin, the implant may be easily recognized due to rippling that is not covered by thicker soft tissue.

A prepectoral breast implant might be a great option for certain patients. The determination as to whether this is the best option would be made at the time of the consultation. As always, ask questions of your doctor and make sure you understand the procedures, their benefits and drawbacks. Knowledge is power and you should always feel empowered to take charge of your health.