2019/06/22 by Tyler Safran, Becher Al‐Halabi, Tassos Dionisopoulos · 1 citation
Medicine · #Breast Implant and Reconstruction #Reconstructive Surgery and Microvascular Techniques #Reconstructive Facial Surgery Techniques
paper · doi:10.1097/prs.0000000000005924
openalex publication_date 2019/06/22 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
Sir: Since the advent of breast implants, innovative techniques have pushed the boundaries of breast reconstruction to achieve safer surgery and improved results. Surgeons and patients alike have shifted their views of acceptable reconstructive outcomes to become more critical and to aim for perfection. For years, breast reconstruction was riddled with complications and variability in aesthetic results. With advances in oncological breast surgery and reconstruction, such as breast-conserving therapy, modern anatomical mastectomies, dermal substitutes, and perfusion imaging, plastic surgeons are now given the opportunity to reconstruct mastectomy defects while preserving the nipple-areolar complex and to utilize more robust skin flaps. Plastic surgery, founded on surgical innovation, has fueled the charge to revisit old, forgotten techniques. This process gave rise to the resurgence of the prepectoral breast reconstruction. Prepectoral breast reconstruction places the implant in a suprapectoral position with or without the use of additional dermal substitutes to reinforce and maintain the implant pocket. This avoids the effects that raising the pectoralis major muscle has on the already compromised mastectomy skin flaps. Early re-adopters have reported better aesthetic results, complete elimination of animation deformity, lower pain scores, and a complication profile similar to that for retropectoral placement.1 With all new techniques, it is important to reflect and trace the origins of such an idea. We, as early adopters and advocates of prepectoral breast reconstruction, sought to catalogue the literature over the years to understand the bibliometrics and highlight the exponential growth of this muscle-sparing technique. A search was performed of the PubMed database for articles pertaining to prepectoral breast reconstruction. The search strategy yielded 1396 articles, of which 108 discussed prepectoral breast reconstruction. Of this group, 62.4 percent (n = 69) were published in the past 2 years, 13.2 percent (n = 14) were published from 2010 to 2016, 1.9 percent (n = 2) were published between 1990 and 2009, and finally 20.8 percent (n = 22) were published prior to 1990. The yearly breakdown and trend are shown in Figure 1. As demonstrated by the clear exponential growth trend, prepectoral breast reconstruction is one of the changes, if not the largest, that has occurred in the plastic surgery literature.Fig. 1.: Number of publications related to prepectoral reconstruction.In addition, there are clear prepectoral “hot spots,” with the United States boasting 59.8 percent (n = 64) of the published articles, followed by Italy with 14.9 percent (n = 16) and the United Kingdom with 9.3 percent (n = 10) of articles. Table 1 lists countries and the number of publications; Figure 2 highlights global hotspot mapping. Table 1. - Publications on Prepectoral Breast Reconstruction and Percentage of Total per Country (1966 to 2018) Country No. of Publications % United States 64 59.8 Italy 16 14.9 UK 10 9.3 Australia 3 2.8 South Korea 2 1.9 Switzerland 2 1.9 The Netherlands 2 1.9 Germany 2 1.9 China 1 0.9 Japan 1 0.9 Australia 1 0.9 Egypt 1 0.9 Brazil 1 0.9 France 1 0.9 South Africa 1 0.9 Fig. 2.: Geographical distribution of publication density on prepectoral breast reconstruction (1966 to 2018).Overall, as surgical evidence grows at head-spinning speeds, it can be quite difficult to stay and feel up to date.2 This phenomenon in medical and surgical literature has been extensively studied.2 Most evidence suggests that there is a growth curve similar to that experienced by prepectoral reconstruction in the past 2 years. Now, this is not to say that there are redundancies in the literature; in fact, we believe that it is quite the opposite. There currently exists a plethora of opportunities and unanswered questions pertaining to this novel technique that currently need attention. These unmet clinical questions are mainly found with direct-to-implant reconstructive techniques, elaboration on Wise pattern or staging techniques, patient-centered outcomes, aesthetic results, and dermal substitute--sparing results.1,3 For new techniques to be perfected and have the greatest benefit for patient-centered care, continued unbiased research needs to be created. Most techniques undergo the typical product lifecycle of introduction, growth, maturity, and decline. As we believers in prepectoral reconstruction continue to log our data and strive to improve our technique, we would like to take this opportunity to invite plastic surgeons in centers around the world to join us. Prepectoral breast reconstruction was once abandoned given the high rates of capsular contracture, implant visibility, explantation, and infection. With new technologies and improved technical understanding, as mentioned above, this old technique now yields a great opportunity. One can only wonder, with new advances in technology, what other old techniques may provide new guidance for better outcomes. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work. Tyler Safran, M.D.Becher Al-Halabi, M.D., M.Sc.Division of Plastic and Reconstructive SurgeryMcGill University Tassos Dionisopoulos, F.R.C.S.C.Division of Plastic and Reconstructive SurgeryJewish General HospitalMontreal, Quebec, Canada