One and Done? Evaluating Prepectoral Direct-to-Implant Breast Reconstruction as a Single-Stage Solution

Improvements in mastectomy techniques have led to increased adoption of single-stage direct-to-implant (DTI) breast reconstruction, yet whether it functions as a true "one-and-done" pathway remains uncertain.. This study evaluates reoperation rates for prepectoral DTI versus two-stage implant-based breast reconstruction (IBBR).

A retrospective review was conducted of all prepectoral breast reconstructions from 2017-2024. Data collected included demographics, operative characteristics, and complications. Complications were categorized as major (readmission/reoperation), minor (managed outpatient), or aesthetic.

A total of 552 breasts (333 patients) were included: 229 DTI and 323 two-stage reconstructions. DTI patients had lower BMI (23.8 vs. 26 kg/m²,p<0.05), lower mastectomy weights (561.1g vs. 653.4g,p<0.05), and more prophylactic mastectomies (59.4% vs. 33.7%, p<0.05). Major complications were significantly lower in DTI (7.0% vs. 19.8%, p<0.05), as were minor complications (21.0% vs. 30.7%,p<0.05). Aesthetic revisions were more common in DTI (15.3% vs. 5.3%,p<0.05), predominantly for fat grafting. Across the reconstructive course, the mean number of surgeries per breast was 1.2 for DTI vs. 2.3 for two-stage (p<0.05).

Prepectoral DTI reconstruction can result in significantly fewer complications and total operations compared to two-stage IBBR. Although aesthetic reoperations were more common in DTI, they were minor and elective. To our knowledge, this is the first and largest prepectoral-only study evaluating revision burden, providing plane-specific data to guide operative planning and patient counseling. Patients can be counseled that DTI reconstruction offers a safe and aesthetically favorable option, with a reduced total number of surgeries and lower complication rates compared to traditional two-stage reconstruction.