The Difference Between Subpectoral and Prepectoral Implant Placement
Implant based breast reconstruction involves reconstructing the breast with an implantable device. Breast implants are FDA-approved devices and an important option for breast reconstruction.
Breast implants are used in both subpectoral and prepectoral reconstruction. The difference between the two is the location of the breast implant placement above or below the chest muscle
- Prepectoral Breast Reconstruction:
- The breast implant is placed above the pectoralis muscle and is supported with a dermal matrix, or internal brassiere
- Tissue expanders are not always required when reconstructing the breast above the muscle
- Subpectoral Breast Reconstruction:
- The breast implant is placed below the pectoralis muscle and is supported by the muscle.
- Tissue expander placement is required to expand the muscle, creating a pocket to place a permanent implant in the future
During a mastectomy, the breast tissue and the support structures within the breast tissue are removed. Historically, the breast was reconstructed by placing the implant underneath the pectoralis, or chest muscle.
The reason for using the subpectoral technique was twofold:
- Implant support
- The muscle supported the implant and allowed for additional tissue coverage of the implant. Additional tissue coverage and support is needed after a mastectomy because all the breast tissue has been removed, leaving only the breast skin and fatty tissue behind. Increasing the tissue coverage over the breast implant results in a more natural look and feel of the breast and reduces the appearance of implant rippling.
- Prevention of capsular contracture
- It was thought that placing the implant below the muscle helped to prevent capsular contracture by providing additional coverage of the breast implant
- When an implant is placed a capsule, or scar tissue, forms around the implant. This a natural and normal healing process of the body.
- In some cases, the capsule that forms around the implant hardens and contracts or tightens. This contraction of the capsule applies pressure to the implant and can aesthetically change the appearance of the breast implant and can cause symptoms such as breast firmness and breast pain
- The cause of capsular contracture is not well understood but theories suggest that a lack of tissue coverage over the implant and infection can play a role in the development of capsular contracture
- Capsular contracture can cause breast asymmetry and discomfort, but typically is not dangerous to the patient’s health
- Capsular contracture can happen after the insertion of any kind of medical implant into the body and is not a condition unique to breast implants
Classification Capsular Contracture in Breast Implants:
- Grade I: The breast is soft and normal
- Grade II: The breast is less soft than normal, and the implant can be palpated
- Grade III: The breast is firm, the implant can be palpated easily, and an asymmetrical distortion of shape can be appreciated
- Grade IV: The breast is hard, tender, painful, and the shape distortion is pronounced or severe
Although there were benefits to placing the implant below the muscle, there were also negative outcomes. These negative outcomes included decreased function of the pectoralis muscle, pectoral animation (deformity of the breast that results from the chest muscle pulling on the implants), chest tightness, and an unnatural look and feel of the breast.
Advances in Implant Reconstruction
Fortunately, advancements in both surgical technique and surgical technology now allow us to place the breast implant above the muscle without sacrificing implant support or soft tissue coverage.
Dr. Spiegel has been on the forefront of prepectoral breast reconstruction and routinely places breast implants above the chest muscle using a dermal matrix she designed to support the implant.
The dermis is the strength layer of our natural body tissue. This matrix is different from mesh as it completely incorporates into your body’s tissue, strengthening it from within.
The dermal matrix is sewn in place in the mastectomy pocket, above the chest muscle, to help support the weight of the implant and acts as an internal brassiere. This matrix also provides another layer of soft tissue coverage between the mastectomy skin and the breast implant. This additional layer of tissue coverage has the added benefit of decreasing the risk of capsular contracture, without needing to place the implant below the pectoralis muscle.
If additional soft tissue coverage is needed to contour the breasts, a second procedure that involves liposuction and fat grafting to the breasts can be completed.
Fat grafting is a procedure where fat is taken from an area of excess (typically the thighs or abdomen), is processed, and then is injected to a different area of the body where the fat is needed. Fat grafting the breasts allows the surgeon to build thickness between the implant and the breast skin, while improving the shape and feel of the breasts. For more information regarding fat grafting please visit the fat grafting information page.
Direct to Implant Placement
This advancement of placing the implant above the muscle has allowed for the option of “direct to implant” placement.
When placing the implant below the muscle, a tissue expander was required to expand the muscle, creating a pocket to allow enough space to place an implant in the future.
Direct to implant refers to immediately placing a permanent breast implant, above the chest muscle, without the need to use a tissue expander. Placing an implant directly depends on multiple factors, but we can now routinely reconstruct the breast with the direct to implant technique.
Some patients will still require a tissue expander as a first stage. The decision to place a tissue expander is based on the type of mastectomy performed and assessment of the blood flow to the mastectomy skin and nipple intraoperatively.
If a tissue expander is needed it will be placed using the prepectoral technique. The expander will be gradually filled with saline through a port in the clinic until we reach your optimal breast size. Once your skin has stretched, or your radiation therapy has been completed, the next surgery will replace the tissue expander with a permanent implant. This is done in conjunction with possible fat grafting to help contour the breast shape.
One incision is made to each breast. The location of the breast incision varies patient to patient. In the case of a nipple sparing mastectomy, the incision will be hidden in the breast crease and results in the look of a completely unoperated breast.
Factors considered when determining incision placement include the type of mastectomy the patient is having, the incision the general surgeon will be using to complete the mastectomy, and specific past surgical history.
Please visit the Breast Cancer page for more information regarding mastectomy options.
You may be a candidate for implant based breast reconstruction if you are in good general health and:
- You are scheduled to have a mastectomy due to a new breast cancer diagnosis or you are considering a prophylactic mastectomy
- You desire a natural look and feel to the breast with a faster recovery time
- You had a previous breast reconstruction with implants placed below your muscle and are experiencing breast discomfort or pectoral animation and would like the implants converted to be placed above your muscle
- You have a complex health history that requires a simpler procedure with shorter time under general anesthesia
Things to consider:
- Advances in breast implants now result in higher quality and longer lasting product, but these devices still need to be monitored and in most cases are not lifetime devices.
- Your implants will be monitored to ensure they are intact with a breast MRI every 5 years
- There is no need to exchange the implant, in a patient with no concerns or symptoms, unless there is an implant rupture
- This reconstruction may require more than one procedure
- When possible, we prefer to place an implant directly, but there are multiple factors that effect this decision including type and location of cancer, type of mastectomy, and desired breast size
- You may require a tissue expander to be placed first. This device will slowly expand your skin to allow for the final implant to be placed
- Some patients elect to have an additional procedure, which involves placing fat to build a thicker layer between the mastectomy skin and implant. This procedure will focus on refining the breast shape.
- All breast reconstruction and breast symmetry procedures, following a mastectomy, are covered by insurance, as legislated in 1998.
There are multiple benefits of implant based reconstruction including:
- Simple procedure with little downtime
- In comparison to autologous reconstruction, implant reconstruction is shorter and simpler procedure with a faster recovery
- Natural feel and appearance of the breast
- Prepectoral breast reconstruction, especially when combined with a nipple sparing mastectomy, can result in the appearance of a natural, unoperated breast
- Maintain breast shape during radiation therapy
- Implant based reconstruction is a great option to maintain the shape and contour of the breast during radiation therapy, if required for your cancer treatment
Breast implants are FDA-approved devices and are an important option for breast reconstruction.
Complications of implant based breast reconstruction may include infection, seroma (fluid developing around the breast implant), capsular contracture (contracted scar tissue causing breast discomfort and firmness), and implant rupture. These complications are reduced by surgical technique, the placement of breast drains, intraoperative antibiotics, patient activity restrictions, and post surgical oral antibiotics.
Patient safety is our number one concern. Dr. Spiegel is dedicated to patient advocacy, advances in breast surgery, and medical safety. For more information and resources regarding breast implant safety and for information regarding BIA-ALCL please visit the Breast Implant Safety information page.
After your breast reconstruction, your breast incisions will be covered with steri-strip tape. You will not be required to do any wound care or dressing changes at home. Surgical drains will be placed. Two drains are placed to each operated breast. You will go home with your drains and you will be taught how to care for the drains at home. Drains are typically removed within 2-3 weeks, depending on the drain output.
Your arm range of motion will be restricted during your initial recovery. We ask that you do not perform repetitive motions with the arms or household chores for the first few weeks after surgery. Limiting your arm range of motion decreases the amount of fluid that accumulates are the breast implant, allowing for drains to be removed sooner. One of the main factors in healing after implant based breast reconstruction is decreasing fluid accumulation around the breast implant. This leads to a quicker recovery and decreases the risk of infection. Most patients will be released to full arm range of motion at 3 weeks and can return to their normal activities 4 weeks after surgery.
As with any surgery, some swelling, bruising, and soreness are to be expected at first. You will be administered pain medication to help control any post-op discomfort. This tenderness and swelling should begin to subside after a few days. The majority of swelling should begin to resolve after a few weeks.
Patients have a short hospital stay where they are observed overnight after their surgery and are discharged the following morning. Patients can return to normal daily activities at approximately four weeks. Most patients can resume all activities without restrictions, including lifting, at 2-3 months. For a detailed layout of what to expect after your implant reconstruction please click here for the Implant Week by Week Guide.
Advances in both mastectomy technique and implant based reconstruction have allowed for excellent short and long term results. Prepectoral implant placement has allowed for a natural contour, shape, and feel to the breast. When combined with a nipple sparing mastectomy, Dr. Spiegel is able to reconstruct the breast to the extent where patient’s note they feel and look as though they have not been operated on.
Advances in silicone breast implant technology have lowered rates of implant rupture and it is not necessary to regularly exchange an intact breast implant in a patient that is doing well with no symptoms or concerns. Maintenance of silicone breast implants includes monitoring the implants with a breast MRI every 5 years to ensure the implants are intact.