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Updated: Aug 6, 2026
Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction
Published on: May 17, 2024
Long-Term Clinical Outcomes and Cost-Utility Analysis of Prepectoral Versus Subpectoral Implant-Based Breast
Federica Grieco1, Marco Driutti2, Emma Zanin1
1Clinic of Plastic and Reconstructive Surgery, Department of Medicine (DMED), Academic Hospital of Udine, Udine, Italy.
Background:
Immediate direct-to-implant (DTI) reconstruction after nipple-sparing mastectomy (NSM) can be performed prepectorally or subpectorally, with variable use of implant-supporting mesh. We compared long-term clinical outcomes and cost-utility of 3 DTI strategies.
Methods:
Consecutive adult women undergoing NSM with immediate DTI at 2 tertiary centers in northeastern Italy (January 1, 2011-Decmeber 31, 2024) were included. Cohorts: prepectoral DTI with mesh, dual-plane subpectoral DTI with mesh, and subpectoral DTI without mesh.
Primary Outcome:
cumulative reconstruction-related reoperation.
Secondary Outcomes:
early (≤ 90 days) and late (> 90 days) complications. EQ-5D-5L utilities were collected prospectively; Quality-Adjusted Life Years (QALYs) were estimated by trapezoidal integration. Hospital/provider costs were captured and standardized to 2024 €; base-case horizon 10 years with 3.5% annual discounting. Probabilistic sensitivity analysis (PSA) (10,000 iterations) quantified uncertainty.
Results:
Of 416 patients (501 reconstructions): prepectoral + mesh n = 215 (42.9%), subpectoral + mesh n = 144 (28.7%), subpectoral no mesh n = 142 (28.3%). Median follow-up 5.9 years. Cumulative reoperation: 13.95% (prepectoral + mesh), 27.08% (subpectoral + mesh), 21.83% (subpectoral no mesh) (P = .008). Mean observed total cost per patient: €8798.50 (prepectoral + mesh), €5235.28 (subpectoral + mesh), €3227.17 (subpectoral no mesh) (P < .001). Time-weighted mean EQ-5D-5L utilities ≈0.830 (prepectoral) versus ≈0.801 (pooled subpectoral). Ten-year discounted base-case: incremental cost ≈€4567 and incremental cost-utility ratio (ICUR) ≈€17,566/QALY for prepectoral versus pooled subpectoral. PSA: ≈68% probability prepectoral is cost-effective at €20,000/QALY.
Conclusions:
Prepectoral DTI with mesh was associated with fewer late complications and reoperations and higher QALYs, at higher upfront cost; some mesh techniques showed increased early seroma/infection rates.