Novel algorithm in decision making process for implant-based breast reconstruction

There has been a renewed interest in the pre-pectoral placement of tissue expanders and implants due to possibility of decreased animation deformity, pain, and hospital stays with similar aesthetic and complication profiles compared to sub-pectoral placement. However, for surgeons who are beginning to offer pre-pectoral device placement, or whom work with breast surgeons who are unfamiliar with this approach, pre-pectoral reconstruction can be daunting. The senior author has developed a step-wise algorithm from the initial consultation to the operating room in an attempt to optimize patient satisfaction, aesthetic outcomes, and minimize complications for pre-pectoral and direct-to-implant (DTI) device placement. We present this algorithm for determining which patients are pre-pectoral candidates and we have identified patient factors that are amenable to a DTI approach as opposed to a two-stage reconstruction with a tissue expander. Finally, considerations for patients undergoing pocket conversion from a sub-pectoral to a pre-pectoral plane are discussed. The pre-pectoral technique is an exciting avenue with numerous potential patient benefits. However, reconstruction failure remains a devastating complication and this proposed algorithm allows physicians to maximize their results while minimizing potential complications.