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Updated: Nov 6, 2025
Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction
Published on: May 17, 2024
"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving
Donato Casella1, Juste Kaciulyte1, Federico Lo Torto1
1From the Azienda Ospedaliera Universitaria Senese, UOC Chirurgia Oncologica della Mammella; Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery; Unità di Oncologia Chirurgica Ricostruttiva della Mammella, "Spedali Riuniti" di Livorno, "Breast Unit" Integrata di Livorno Cecina, Piombino Elba; Department of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese; Plastic and Reconstructive Surgery Unit, San Giovanni-Addolorata Hospital; and the Department of Plastic Surgery, University of Catanzaro Hospital.
Background:
Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction.
Methods:
Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed.
Results:
Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement.
Conclusions:
To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure.
Clinical Question/Level Of Evidence:
Therapeutic, IV.
