A Closer Look at Prepectoral Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Direct-to-Implant versus 2-Stage Outcomes

Abstract

Background: Direct-to-implant (DTI) reconstruction offers several advantages over the 2-stage implant-based breast reconstruction approach. However, the outcomes of prepectoral reconstruction are debated. Many previous studies contained confounders, making their conclusions less definitive. This study offers the first matched cohort analysis comparing DTI with 2-stage reconstruction in the prepectoral plane.

Methods: Patients treated with postmastectomy implant-based breast reconstruction from 2018 through 2021 were retrospectively reviewed. Patients were propensity score matched by body mass index, smoking status, history of hypertension, mastectomy type, chemotherapy, radiotherapy, acellular dermal matrix use, and coverage type. Outcomes assessed included surgical site occurrences (SSOs), capsular contracture, and explantation of either expander or implant.

Results: A total of 433 breasts were identified, and 154 breasts were matched (77 DTI; 77 2-stage). Two-stage prepectoral reconstruction was associated with greater rates of seromas (2-stage, 18.2%; DTI, 5.2% [ P < 0.05]) and overall SSOs (2-stage, 45.5%; DTI, 24.7% [ P < 0.05]). This approach was also an independent predictor on multivariate regression (adjusted odds ratio, 5.69, 4.86 [ P < 0.05]). There were no differences between the groups regarding final implant size, capsular contraction (grades 3 or 4), or implant or expander loss ( P > 0.05). There were also no significant differences in secondary reconstruction or failures of secondary reconstructions after explantation between the groups, with a mean follow-up of 22 months.

Conclusions: Prepectoral 2-stage and DTI reconstruction have similar risk profiles; however, DTI may be more beneficial in the correctly identified patient. Prepectoral 2-stage reconstruction is associated with higher rates of seromas and SSOs compared with DTI reconstruction. Secondary reconstruction after explantation can readily achieve long-term success in both prepectoral 2-stage and DTI reconstruction.