Prepectoral versus Retropectoral Direct to Implant Breast Reconstruction after Skin-reducing Mastectomy: A Systematic Review and Meta-analysis.

BACKGROUND: Skin-reducing mastectomy (SRM) enables single-stage implant-based breast reconstruction (IBBR) in women with large or ptotic breasts. The optimal implant plane after SRM remains debated. Retropectoral placement provides reliable coverage but is associated with pain and animation deformity, whereas prepectoral placement avoids muscle dissection but requires well-vascularized and thicker skin flaps. METHODS: A systematic review and meta-analysis was conducted according to PRISMA guidelines (PROSPERO ID: 1019974). Databases were searched in April 2025. Eligible studies reported outcomes of SRM followed by single-stage prepectoral or retropectoral IBBR. The primary outcome was breast complications; secondary outcomes included aesthetic and patient-reported outcomes (PROs). A random-effects proportional meta-analysis was performed. RESULTS: Twenty-six studies comprising 863 patients and 1106 reconstructions were included (432 prepectoral and 674 retropectoral). The pooled complication rate was similar between prepectoral and retropectoral reconstruction (20% versus 25%), with no statistically significant differences in any specific complication, including implant loss, skin necrosis, nipple-areolar complex necrosis, wound dehiscence, superficial epidermolysis, capsular contracture, and rippling. PROs favored prepectoral placement, with consistently high BREAST-Q scores across psychosocial, sexual, and satisfaction domains. CONCLUSIONS: In women with large ptotic breasts undergoing SRM with single-stage IBBR, prepectoral and retropectoral reconstruction show comparable overall safety. Given the favorable PRO trends, prepectoral placement may be preferred, although these differences did not reach statistical significance.