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Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction
Published on: May 17, 2024
Prepectoral versus Subpectoral Implant-Based Breast Reconstruction: Evaluating the Shift
Holly Cordray1, Salman Khan1, Malia Voytik2
1From the Perelman School of Medicine at the University of Pennsylvania.
Background:
This study evaluated trends in implant-based breast reconstruction, anticipating a shift toward prepectoral implants instead of subpectoral implants, and correlated these shifts with clinical outcomes.
Methods:
The cohort included adult patients who received implant-based breast reconstruction at the University of Pennsylvania Health System from 2018 through 2024. Analyses used linear regression to trend implant plane selection over time, and chi-square/Fisher tests with relative risk (RR) to compare postoperative complications by reconstructive approach.
Results:
Among 686 patients, reconstructions were subpectoral (301 cases) or prepectoral (385 cases). Prepectoral reconstructions rose significantly across the study period ( P = 0.001), from 4.0% of cases in 2018 to 90.2% in 2024. Prepectoral reconstructions showed significantly lower incidence of postoperative fat necrosis (RR, 0.3; 95% CI, 0.1 to 0.9), nipple-areola complex necrosis (RR, 0.2; 95% CI, 0.1 to 0.5), and chronic pain (RR; 0.3; 95% CI, 0.1 to 0.8). Prepectoral reconstructions showed significantly higher incidence of infection (RR, 3.3; 95% CI, 2.0 to 5.5), delayed healing/dehiscence (RR, 2.0; 95% CI, 1.3 to 2.9), readmission (RR, 2.1; 95% CI, 1.2 to 3.6), and reoperation for complications (RR, 2.0; 95% CI, 1.5 to 2.8). Prepectoral reconstructions showed higher reoperation rates for threatened prosthetic loss (RR, 2.9; 95% CI, 1.7 to 4.9) and prosthetic failure rates (RR, 2.8; 95% CI, 1.5 to 5.2).
Conclusions:
Implant plane preference reversed across 2018 to 2024, from subpectoral to prepectoral. Despite certain advantages, prepectoral (versus subpectoral) reconstructions showed twice the risk of readmission and reoperation, including a nearly 3-fold risk of reoperation for threatened prosthetic loss and ultimate failure. These results warrant further study to determine ways to improve outcomes following prepectoral reconstruction or whether surgeons should revisit subpectoral placement in predetermined high-risk cases.
