An algorithmic approach to implant based immediate breast reconstruction

Implant based breast reconstruction (IBR) remains the most commonly performed reconstructive approach following mastectomy. Contemporary practice has evolved significantly through advances in implant technology, availability of biological and synthetic meshes, and the establishment of prepectoral IBR as an alternative to the traditional subpectoral technique. Patient selection and operative planning remain complex, particularly in the setting of varying breast anatomy, ptosis, skin quality, nipple preservation, and anticipated adjuvant therapies. The aim of the presented algorithm is to support decision-making in IBR providing a structured approach based on four principal considerations: nipple-versus skin-sparing mastectomy, the use of acellular dermal matrix (ADM), one-stage versus two-stage reconstruction, and the requirement for nipple-areola complex repositioning or skin reduction. Patients are stratified into four reconstructive categories according to breast size, degree of ptosis, and extent of skin adjustment required. For each category, tailored reconstructive pathways are proposed, incorporating considerations of pocket stability, skin quality, use of tissue expansion, and the role of different ADM-assisted techniques. This structured framework aims to facilitate consistent patient selection, optimise aesthetic and oncologic outcomes, and support shared decision-making between surgeons and patients.