Pocket Conversion from Prepectoral to Retropectoral Implant Placement in Breast Reconstruction: A Cost-effective Solution for High-Grade Rippling and Implant Visibility.

backgroundImmediate prepectoral breast reconstruction (PBR) after conservative mastectomy has gained widespread adoption in recent years, demonstrating excellent outcomes in terms of function, aesthetics, and patient-reported satisfaction. However, as with all surgical advancements, the increasing use of prepectoral techniques has also introduced new limitations and complications. Among these, implant rippling and implant visibility are the most common reasons for revision surgery after PBR. While autologous fat grafting is the most frequently employed technique for revision-aimed at enhancing skin flap thickness and contour-this solution is not viable for all patients. In particular, patients with limited donor sites or those exhibiting high-grade rippling may require alternative surgical approaches.

aimThis study aims to describe our management of patients who previously underwent PBR and presented with high-grade rippling or a "flying saucer effect," where autologous fat grafting was not feasible. In these cases, we performed a pocket conversion from prepectoral to retropectoral implant placement. Our surgical technique reuses the existing periprosthetic capsule of the prepectoral implant, avoiding the use of acellular dermal matrices and thereby eliminating additional costs. This article details our technique and evaluates the resulting aesthetic and patient-reported outcomes.

methodsWe conducted a prospective observational study from November 2022 to October 2024, enrolling all patients with prior PBR who presented with unsatisfactory aesthetic outcomes (high-grade rippling or implant visibility) for whom fat grafting was not a viable option. Collected data included patient age, side of surgery, indication for mastectomy, eventual radiation therapy or previous fat graft, reasons for implant revision, and postoperative complications. Aesthetic outcomes were assessed using a 5-point Likert scale, evaluating breast shape, symmetry, and overall satisfaction. Patient satisfaction was measured using the BREAST-Q Reconstruction Module, evaluating the domains "Satisfaction with Breasts" and "Satisfaction with Outcome," both preoperatively and at 1-year follow-up.

resultsFourteen breasts from seven patients (mean age 46.2 years, range 34-65) underwent pocket conversion. All patients had undergone bilateral nipple-sparing mastectomy and immediate PBR. Mean follow-up was 15.2 months (range 12-25). One minor complication (7.1%) was recorded: a seroma requiring office drainage. No implant removals, infections, or deformities were reported. All cases showed complete resolution of rippling and/or implant visibility. No animation deformity was observed. Mean aesthetic scores (Likert scale) were 4.4 for breast shape, 4.3 for symmetry, and 4.4 for global satisfaction. BREAST-Q analysis showed significant improvement: the "Satisfaction with Breasts" domain increased by 21.7 points (p = 0.001), and "Satisfaction with Outcome" increased by 19.0 points (p = 0.007) at one-year follow-up.

conclusionThis study proposes a simple, safe, and cost-effective solution for patients with limited fat donor availability and/or high-grade rippling or implant visibility following PBR. Although limited by small sample size, our findings support retropectoral conversion using the posterior capsule as a reliable revision technique. Further large-scale, long-term studies are warranted to validate these results and optimize revision strategies in complex breast reconstruction cases. LEVEL OF EVIDENCE III: This 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 .