Prepectoral Breast Reconstruction May Reduce Pain for Some Breast Cancer Patients

For the last few decades, it’s been standard practice to place breast implants under the pectoral muscle. Surgeons in the 1970s tried placing implants above the chest muscle, where the breast tissue would naturally be, but there were too many complications with this type of implant surgery. Such complications included higher infection rates, more significant buildup of scar tissue due to the body’s immune response to the foreign object, and the potential for the skin to wear away over time and expose the implant beneath.

However, placing implants underneath the pectoral muscle has its issues too. The surgeon cuts parts of the pectoralis muscle, separates it from the ribs, and creates a pocket underneath it for the implant, permanently stretching it out. The surgery can cause chronic pain and muscle weakness in the chest and arms, and some patients experience loss of range of motion, shoulder pain, or the inability to take a full deep breath. It also often causes an unnatural and unsightly deformity of the breasts whenever the pectoralis major contracts.

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Hani Sbitany, MD, a plastic and reconstructive surgeon at UCSF Health, has been working on a new reconstruction procedure, known as prepectoral reconstruction, which involves placing the implant above the pectoral muscle again—with tweaks, of course, to protect women from the original complications involved in the procedure.

When Dr. Sbitany places an implant above the pectoral muscle, he surrounds it with a biologic mesh which is essentially a layer of collagen. This preserves the muscle and the implant and keeps the body from developing a thick buildup of scar tissue, as well as creating a nicer contoured shape in the breast. Better breast implants have also been developed over the decades, which contribute to the success of this procedure.

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“What’s changed is now we have acellular dermal matrices (biologic mesh),” said Maurice Nahabedian, MD, formerly of Johns Hopkins University and Georgetown University and now in private practice. “We do fat grafting all the time, we have better quality mastectomies, and we have better implants. And we’ve really been able to capture the benefits. I can’t even imagine going back to putting an implant back under the muscle anymore.”

Dr. Sbitany’s approach is less invasive than current breast implant surgeries, involves a less painful recovery, and results in more natural-looking breasts. It’s also a safer option for patients who will be undergoing radiation therapy after their mastectomies. These changes make a significant difference for the women undergoing such procedures.

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“Our preliminary data shows that by avoiding the muscle and offering a prepectoral approach we’re potentially reducing opioid medication and narcotic medication use by up to 70 percent in our patients, just by avoiding the muscle dissection,” said Sbitany. “In this day of the opioid epidemic, that’s really significant.”

Dr. Sbitany and other surgeons are publishing research on the subject and promoting the idea at national surgery conferences. Hopefully word will continue to spread so that this procedure can become more widely available. You can help by sharing this story!

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