In 49 patients and 70 breasts NSM and single-stage direct-to-implant breast reconstructions with prepectoral implant placement and complete coverage with ADM was performed. The mean age of the patients was 47 years (min 26, max 74 years). 21/49 patients were treated with bilateral mastectomy, and 28/49 patients were treated with a unilateral mastectomy. Eleven patients were BRCA 1 and/or BRCA2 gene mutation carriers. Nine of those patients were diagnosed with unilateral breast cancer and had a bilateral NSM. Two of the mutation carriers received bilateral risk-reducing mastectomy. Ten of 21 patients with bilateral NSM were diagnosed with unilateral invasive breast cancer and chose a contralateral risk-reducing mastectomy due to fear of a second breast cancer in the other breast or due to strong family history of cancer without BRCA gene mutation. Twenty-eight of 49 patients with unilateral NSM were diagnosed with invasive multicentric breast cancer or extensive DCIS or were patients with recurrent breast cancer in the same breast. Eight patients had NSM after preoperative chemotherapy. Twelve patients had received some form of radiotherapy, six of 12 patients had radiotherapy after NSM and DTI reconstruction. Six of 12 patients were diagnosed with recurrent invasive breast cancer or recurrent DCIS and had a history of radiotherapy. The mean age of the patients was 47 years (range 26–74 years), the mean volume of the removed breast was 291 ml (range 59–875 ml) and the mean implant weight was 300 g (range 135–540 g). Nipple-sparing mastectomy was performed in all patients. In most patients, the inframammary fold incision was chosen, which is the standard incision for most patients if possible [3]. In some cases lateral S-shaped incisions, vertical incisions, or periareolar incisions were performed, depending on the former incision for lumpectomy or segmentectomy , or when skin excision was necessary due to close or positive margins (Table 14.2).

For NSM the injection of tumescent solution was used in most cases. After injection of 20–40 ml of tumescent solution (5 Units vasopressin/100 ml of saline solution) per breast, the skin envelope was dissected from the breast gland carefully with blunt scissors. The dissection of the breast gland from the pectoralis major muscle was performed by electrocautery. After removal of the complete breast gland, the volume and weight of the breast gland were measured and the implant size could be determined. As most patients wanted their reconstructed breasts looking natural and like their original breasts, we used anatomical implants and implant sizes resembling the removed breast volume. The pectoralis major muscle was left entirely intact and the pocket was washed with antibiotic solution. Then the ADM was prepared to cover the implant and keep the implant in place. We used the porcine ADM Strattice™ (LifeCell™ Corporation, Bridgewater, NJ, USA) for total implant coverage. Since pliable matrices in the desired size were not available in Europe, two sheets of Strattice™ 8×16 cm were joined by suturing the long sides of the two sheets with interrupted Vicryl^® 3/0 sutures after thorough washing of the ADM. The enlarged 16×16 cm ADM was incised twice on every edge and trimmed as illustrated in Fig. 14.1. This type of incision allows the creation of four straight flaps (to be fixed by sutures) and four angular flaps at the corners (to be wrapped around the implant). This large sheet of ADM was then placed to create the implant pocket. The superior straight flap of the ADM was fixed primarily to the fascia of the PMM or the overlying tight connecting tissue with three interrupted sutures after marking the optimal suture sites from outside. The next step was to fix the medial straight flap of ADM to the fascia with 3 sutures. Then the implant with the appropriate size was placed prepectorally beneath this ADM envelope. We used exclusively highly cohesive anatomically shaped silicone gel-filled implants (Allergan^®, Inc., Irivine, California, USA; Natrelle 410^®). The angular ADM flaps were wrapped around the implant medial-cranially and medial-caudally as well as lateral-cranially and lateral-caudally, so that a complete ADM-covered implant pocket was achieved. Then three sutures fixed the lateral straight flap, and in the final step three interrupted sutures were used to fix the caudal straight flap to the fascia to define the inframammary fold . During all the steps of implant fixation attention has to be turned to the position of the pocket in the breast and according to symmetry with the contralateral breast. With this suture technique the implant can be kept in an exact position and an implant malposition can be prevented. One suction drain was inserted and a double layer wound closure was performed with Monocyrl^® 4.0 interrupted sutures and Monocryl^® 5.0 running sutures for skin closure . After wound dressing all patients were adequately supplied with a surgical compression bra.

In total 70 breasts were reconstructed by using the described procedure. After informed consent all patients decided against PMM detachment or dissection, and asked for prepectoral implant placement with complete ADM coverage.

Postoperative complications (Table 14.3) included minimal nipple necrosis without further intervention followed by complete healing in 4 breasts, and hematoma with evacuation in 4 breasts. In one patient the implant had to be removed 4 weeks after radiotherapy due to massive swelling, edema, and pain. Breast pain was not recorded in the other patients and no analgesics were required after surgery. Arm-shoulder mobility showed no restrictions and no motion-associated pain was reported. Mean duration of drainage was five days.