Background: Much has been written regarding the new paradigm of prepectoral direct-to-implant reconstruction, but patient selection continues to be unclear. Prepectoral direct-to-implant (PDTI) reconstruction with acellular dermal matrix drape and fluorescent imaging (ADFI) was offered to all patients.
Methods: The PDTI with ADFI protocol is (1) fluorescent imaging following mastectomy, (2) acellular dermal matrix prepectoral drape construction, (3) direct-to-implant placement beneath drape, and (4) repeated fluorescent imaging with implant in place.
Results: Patient ages ranged from 29 to 82 years, and body mass index ranged from 19 to 48 kg/m. Implant size ranged from 240 to 800 cc. Two hundred thirty breasts in 131 patients were reconstructed with the PDTI with ADFI protocol between October of 2016 and June of 2018; 32 patients underwent unilateral and 99 underwent bilateral reconstruction. Twelve breasts (5 percent) received postmastectomy radiation therapy after reconstruction. Ten patients (8 percent) had previous lumpectomy and radiation therapy, with local recurrence, and underwent completion mastectomy and PDTI reconstruction with ADFI. Fifteen patients and 22 breasts (9 percent) had subpectoral reconstructions converted to PDTI with ADFI. Ten infections (4 percent) required explantation. Eight breasts (4 percent) were reconstructed with tissue expanders because of poor vascular flow. Seven breasts (3 percent) in five patients received minor cosmetic revision.
Conclusions: SPY fluorescent imaging and expanded use of acellular dermal matrices has created an environment where PDTI reconstruction can be successful in nearly all postmastectomy patients. Tissue expansion/two-stage reconstruction has evolved to a default approach when vascular supply to skin flaps is compromised. PDTI reconstruction with ADFI has resulted in zero necroses of skin flaps, patients rarely undergoing revisions, fewer office visits, and quicker return to preoperative lifestyles.
Clinical question/level of evidence: Therapeutic, IV.