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Pre- versus Subpectoral Tissue Expander Placement in Immediate Latissimus Flap Breast Reconstruction
A. Samandar Dowlatshahi; Martha Luitje; Robert Quinlan; Mustafa Akyurek
Division of Plastic Surgery, University of Massachusetts Medical School, Worcester, MA

Background: Breast reconstruction with use of a latissimus flap and tissue expander is well-established, requiring elevation of the pectoralis major with subpectoral implant placement. This paper presents the approach of prepectoral expander placement in immediate breast reconstruction with latissimus flap.

Methods:86 immediate reconstructions were performed in 55 consecutive patients over a 7-year-period. In the prepectoral group (50 reconstructions), the tissue expander was placed over the pectoralis muscle being covered entirely by the latissimus flap. In the subpectoral group (36 reconstructions), the expander was placed in a subpectoral pocket. Three months later, the expander was exchanged for a permanent implant.

Results: The demographics comparing the prepectoral versus subpectoral groups were similar in terms of age (52.4y8.59 vs 52.512.1; p=0.97), smoking history (40%vs32%; p=0.78), radiation history (36%vs41%; p=1.00), and follow up (479d326 vs 680494; p=0.07). BMI was significantly higher in the prepectoral group (27.6kg/m24.3 vs 25.23.2; p=0.03). Major complications (hematoma, DVT/PE, implant infection) were comparable (p=0.26,p=1,p=0.64). The rate of donor site seroma was higher in the prepectoral group (64%vs42% of reconstructions; p=0.05).

Conclusion: Prepectoral expander placement is a safe and reliable approach, with comparable outcomes and complication rates to the subpectoral approach. The incidence of donor site seroma in the prepectoral group is possibly related to a more extensive latissimus dissection. The prepectoral technique offers the advantages of avoiding pectoralis elevation and its associated morbidity. Most importantly, is easier to recreate the medial breast border with this approach, and the subpectoral plane is preserved for a future site change, in the event of capsular contracture.

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