ABSTRACT **Background:** Post-mastectomy breast reconstruction represents an important component of the therapeutic pathway for patients undergoing surgical treatment for breast cancer. Implant-based reconstruction can be performed using different anatomical planes, primarily the subpectoral and prepectoral planes. The evolution of surgical techniques and the use of acellular dermal matrices have contributed, in recent years, to the increasing adoption of prepectoral reconstruction. However, the choice of implant placement plane remains a subject of debate, depending on patient anatomical characteristics, oncological treatment, and the associated complication profile. **Objective:** The aim of this thesis is to analyze and compare the main characteristics of implant-based breast reconstruction using prepectoral and subpectoral implant placement, with particular attention to the advantages, limitations, postoperative complications, and functional and aesthetic outcomes associated with the two techniques. **Methods:** A review of the available scientific literature was conducted, with particular reference to comparative studies, systematic reviews, and meta-analyses published on the comparison between prepectoral and subpectoral breast reconstruction. The anatomical and technical aspects of the two procedures were analyzed, as well as the main clinical outcomes, including seroma, hematoma, infection, skin flap necrosis, capsular contracture, implant loss, reoperation, postoperative pain, dynamic deformity (animation deformity), rippling, and patient satisfaction. **Results:** The analysis of the literature indicates that both techniques represent valid approaches for post-mastectomy breast reconstruction in appropriately selected patients. Prepectoral reconstruction allows preservation of the pectoralis major muscle, avoiding muscle dissection and significantly reducing the risk of animation deformity. Some systematic reviews and meta-analyses have also reported a potential reduction in capsular contracture and postoperative pain compared with subpectoral reconstruction. On the other hand, prepectoral implant placement requires adequate quality and perfusion of the skin flaps and may be associated with greater implant visibility, rippling, and, in some studies, a higher incidence of seroma. Overall, many of the main postoperative complications, including infection, hematoma, skin necrosis, and implant loss, show comparable rates between the two approaches, although the heterogeneity of the studies and patient selection limit the possibility of drawing definitive conclusions. **Conclusions:** Prepectoral reconstruction represents an important evolution in post-mastectomy reconstructive surgery and constitutes a valid alternative to traditional subpectoral reconstruction. Its main anatomical and functional advantage is preservation of the pectoralis major muscle, with a consequent reduction in dynamic deformity. However, the choice of implant placement plane should be individualized based on the patient's anatomy, the quality and vascularization of the skin flaps, oncological characteristics, the potential need for radiotherapy, and aesthetic and functional goals. The currently available evidence therefore supports a personalized approach, highlighting the need for further high-quality comparative studies to more precisely define the long-term indications for the two techniques. **Keywords:** Breast reconstruction; mastectomy; implant-based breast reconstruction; prepectoral reconstruction; subpectoral reconstruction; acellular dermal matrices.
ABSTRACT Background: La ricostruzione mammaria post-mastectomia rappresenta una componente importante del percorso terapeutico delle pazienti sottoposte a trattamento chirurgico per carcinoma della mammella. La ricostruzione mediante impianto protesico può essere eseguita attraverso differenti piani anatomici, principalmente quello sottopettorale e quello prepettorale. L’evoluzione delle tecniche chirurgiche e l’impiego di matrici dermiche acellulari hanno favorito, negli ultimi anni, una progressiva diffusione della ricostruzione prepettorale. Tuttavia, la scelta del piano di posizionamento dell’impianto rimane oggetto di discussione, in relazione alle caratteristiche anatomiche della paziente, al trattamento oncologico e al profilo di complicanze. Obiettivo: L’obiettivo di questa tesi è analizzare e confrontare le principali caratteristiche della ricostruzione mammaria mediante impianto protesico con posizionamento prepettorale e sottopettorale, con particolare attenzione ai vantaggi, ai limiti, alle complicanze postoperatorie e agli aspetti funzionali ed estetici associati alle due tecniche. Metodi: È stata effettuata una revisione della letteratura scientifica disponibile, con particolare riferimento agli studi comparativi, alle revisioni sistematiche e alle meta analisi pubblicate sul confronto tra ricostruzione prepettorale e sottopettorale. Sono stati analizzati gli aspetti anatomici e tecnici delle due procedure e i principali outcome clinici, tra cui sieroma, ematoma, infezione, necrosi del lembo cutaneo, contrattura capsulare, perdita dell’impianto, reintervento, dolore postoperatorio, deformità dinamica (animation deformity), rippling e soddisfazione della paziente. Risultati: L’analisi della letteratura evidenzia che entrambe le tecniche rappresentano approcci validi per la ricostruzione mammaria post-mastectomia in pazienti adeguatamente selezionate. La ricostruzione prepettorale consente di preservare il muscolo grande pettorale, evitando la sua dissezione e riducendo significativamente il rischio di animation deformity. Alcune revisioni sistematiche e meta-analisi hanno inoltre riportato una possibile riduzione della contrattura capsulare e del dolore postoperatorio rispetto alla ricostruzione sottopettorale. D’altra parte, il posizionamento prepettorale richiede un’adeguata qualità e perfusione dei lembi cutanei e può essere associato a una maggiore evidenza del dispositivo, rippling e, in alcuni studi, a una maggiore incidenza di sieroma. Nel complesso, molte delle principali complicanze postoperatorie, tra cui infezione, ematoma, necrosi cutanea e perdita dell’impianto, presentano risultati comparabili tra i due approcci, sebbene l’eterogeneità degli studi e la selezione delle pazienti limitino la possibilità di formulare conclusioni definitive. Conclusioni: La ricostruzione prepettorale rappresenta un’importante evoluzione della chirurgia ricostruttiva post-mastectomia e costituisce una valida alternativa alla tradizionale ricostruzione sottopettorale. Il principale vantaggio anatomico e funzionale è rappresentato dalla preservazione del muscolo grande pettorale e dalla conseguente riduzione della deformità dinamica. Tuttavia, la scelta del piano protesico deve essere individualizzata sulla base dell’anatomia della paziente, della qualità e vascolarizzazione dei lembi cutanei, delle caratteristiche oncologiche, dell’eventuale radioterapia e degli obiettivi estetici e funzionali. Le evidenze attualmente disponibili supportano pertanto un approccio personalizzato, sottolineando la necessità di ulteriori studi comparativi di elevata qualità metodologica per definire con maggiore precisione le indicazioni a lungo termine delle due tecniche.
Ricostruzione mammaria pre pettorale e retro pettorale
MADAH, FARES
2025/2026
Abstract
ABSTRACT **Background:** Post-mastectomy breast reconstruction represents an important component of the therapeutic pathway for patients undergoing surgical treatment for breast cancer. Implant-based reconstruction can be performed using different anatomical planes, primarily the subpectoral and prepectoral planes. The evolution of surgical techniques and the use of acellular dermal matrices have contributed, in recent years, to the increasing adoption of prepectoral reconstruction. However, the choice of implant placement plane remains a subject of debate, depending on patient anatomical characteristics, oncological treatment, and the associated complication profile. **Objective:** The aim of this thesis is to analyze and compare the main characteristics of implant-based breast reconstruction using prepectoral and subpectoral implant placement, with particular attention to the advantages, limitations, postoperative complications, and functional and aesthetic outcomes associated with the two techniques. **Methods:** A review of the available scientific literature was conducted, with particular reference to comparative studies, systematic reviews, and meta-analyses published on the comparison between prepectoral and subpectoral breast reconstruction. The anatomical and technical aspects of the two procedures were analyzed, as well as the main clinical outcomes, including seroma, hematoma, infection, skin flap necrosis, capsular contracture, implant loss, reoperation, postoperative pain, dynamic deformity (animation deformity), rippling, and patient satisfaction. **Results:** The analysis of the literature indicates that both techniques represent valid approaches for post-mastectomy breast reconstruction in appropriately selected patients. Prepectoral reconstruction allows preservation of the pectoralis major muscle, avoiding muscle dissection and significantly reducing the risk of animation deformity. Some systematic reviews and meta-analyses have also reported a potential reduction in capsular contracture and postoperative pain compared with subpectoral reconstruction. On the other hand, prepectoral implant placement requires adequate quality and perfusion of the skin flaps and may be associated with greater implant visibility, rippling, and, in some studies, a higher incidence of seroma. Overall, many of the main postoperative complications, including infection, hematoma, skin necrosis, and implant loss, show comparable rates between the two approaches, although the heterogeneity of the studies and patient selection limit the possibility of drawing definitive conclusions. **Conclusions:** Prepectoral reconstruction represents an important evolution in post-mastectomy reconstructive surgery and constitutes a valid alternative to traditional subpectoral reconstruction. Its main anatomical and functional advantage is preservation of the pectoralis major muscle, with a consequent reduction in dynamic deformity. However, the choice of implant placement plane should be individualized based on the patient's anatomy, the quality and vascularization of the skin flaps, oncological characteristics, the potential need for radiotherapy, and aesthetic and functional goals. The currently available evidence therefore supports a personalized approach, highlighting the need for further high-quality comparative studies to more precisely define the long-term indications for the two techniques. **Keywords:** Breast reconstruction; mastectomy; implant-based breast reconstruction; prepectoral reconstruction; subpectoral reconstruction; acellular dermal matrices.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/28488