I recently attended a meeting of the Fort Worth Society of Plastic Surgeons on the topic of breast reconstruction in front of the pectoralis muscle (pre-pectoral). The speaker at the meeting was Michelle Roughton, a clinical assistant professor in the plastic surgery division at the University of North Carolina.
She presented a very nice series including a year of impressive follow-up data on breast reconstruction utilizing this approach. Most breast reconstruction is done sub-pectoral (under the pectoralis muscle) because it gives the implant coverage from the overlying tissues, and the rate of capsular contracture (the breast and/or implant becoming "hard") was less than when the pre-pectoral approach was used. In fact, the incidence of capsular contracture was so high that most surgeons abandoned the pre-pectoral approach.
However, recently with the use of ADM's (regenerative tissue matrix, such as alloderm), results have improved. While it is difficult to categorically state that the use of the alloderm is preventing the capsular contractures, there certainly seems to be something going on that is giving more positive results. One of the advantages of performing breast reconstruction in this manner, is that a much larger implant can be positioned initially, thereby avoiding the process of "expansion" via a breast implant expander, placed under the muscle, and then having to return to surgery to swap out the expander for a permanent implant. This can make the reconstruction a one stage process with the mastectomy.
There are some technical aspects of the procedure which include creating a "tight" pocket for the implant and alloderm among other things. However, this is an exciting addition to our ability to reconstruct breasts and placing the implant in front of the muscle is once again an option. This gives our patients another possible option to feel "whole" again, and with appropriate selection, can make the reconstructive process shorter.