Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction

IntroductionPre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR.MethodsA literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction.ResultsImplant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling.ConclusionSurgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Automated summary

Pre-pectoral implant-based breast reconstruction (IBR) is popular for its advantages, but there are concerns about increased rates of implant rippling. This study identified factors and technical strategies that can be implemented to reduce implant rippling in pre-pectoral IBR. The majority of studies reviewed did not find a significant association between BMI and rippling, suggesting that other factors contribute to implant rippling. Surgical modifications and attention to various technical aspects can potentially reduce the incidence of rippling in pre-pectoral breast reconstruction.