• complications
• immediate breast reconstruction
• pre-pectoral
• prothesis

Introduction: Female breast cancer is the most commonly diagnosed cancer all over the world. In Italy alone there are around 55.000 new cases per year. We assisted to a progressive change over time in the concept of breast surgery, from extremely demolitive without any type of reconstruction to oncoplastic and conservative mastectomy. Even the concept of reconstruction changes all over time, with an initial abandon of the pre-pectoral one in favor of a subpectoral one. With the introduction of meshes in the 2000’s, assuming that subpectoral reconstruction has many disabling complications, we assisted to a tourn back to the immediate pre-pectoral prothesis reconstruction which permits a pectoralis major sparing.
The most important thing for the mastectomy success is the evaluation of the skin-dermal flaps, in order to decide between the various type of reconstruction: if the flaps are too thin, it still remain better to perform a subpectoral reconstruction to diminish the risk of skin flap necrosis ore dehiscence; Rancati et al set the limit of a good flap thickness of 2 cm, with a grey zone between 1 and 2 cm. Many techniques have been proposed to evaluate the flaps’ perfusion, like indocyanine green or spectroscopy.
Aside from the thickness, there are many risk factors related directly to the patients which have been involved in the reconstructive decision.
This study is focused on the experience in our Centre in order to find out potential risk factors in the direct to implant pre-pectoral reconstruction following a mastectomy, because patients ask always more for the best aesthetic outcome aside from the oncologic one, changing the view to a patient centered model. We focused on the pre-pectoral immediate reconstruction because it has the more natural outcome and results in the lesser discomfort for the patient.
Material and methods: in this retrospective study, we relate the outcomes to the risk factors in 462 consecutive female patients undergone pre-pectoral direct to implant reconstruction after both therapeutic and prophylactic mastectomy, between 1st January 2019 to 30th June 2022.
Results: in our population we found out that neoadjuvant chemotherapy and previous thoracic radiotherapy influence the overall complications rate in a statistically significant way. Investigating the specific complications, we found an augmented risk of dehiscence when skin-reducing mastectomy is performed (p<0.001), when the BMI is less than 18 (p 0.048) and in smokers (p 0.033); of those risk factors only the type of mastectomy was confirmed at the multivariate analysis (OR 3.83), while the smoking habit has a borderline value (p 0.114). Another relation found was that previous breast surgery (p 0.002) and previous thoracic radiotherapy (p 0.001) influence the capsular contracture rate, even if only the previous radiotherapy was confirmed at the multivariate analysis (OR 13). Finally, biological meshes were related to a higher seroma onset (p<0.001), in accordance with the literature.
Conclusions: immediate pre-pectoral breast reconstruction is surely the way to guarantee the best aesthetic and physical outcome, but the woman needs to be well selected. Fundamental is to find an algorithm in order to select the fittest patients who could benefit from this reconstructive technique, who have the less risk factors which could compromise the final result. New materials and meshes help the surgeon, but the most important thing is to evaluate the patient from all the point of view to guarantee the best and safer outcome.