Comparison of Secondary Procedures and Complications Between Subpectoral and Prepectoral Direct-to-implant-based Breast Reconstruction: 5-year Retrospective Analysis.

BACKGROUND: Implant-based breast reconstruction (IBR) remains the most widely used method for breast reconstruction following mastectomy. There is significant variability in the choice between subpectoral and prepectoral approaches. This study compares the frequency of secondary procedures required to improve the aesthetic outcome between subpectoral and prepectoral IBR approaches. METHODS: A retrospective cohort study was conducted on patients undergoing single-stage subpectoral IBR between January 2014 and June 2017 or prepectoral IBR between November 2016 and December 2019 by a single surgeon at a tertiary breast unit. The primary outcome was the number of secondary procedures performed within 5 years to improve aesthetic outcomes. Secondary outcomes included postoperative complications. RESULTS: A total of 388 single-stage IBRs were analyzed (194 subpectoral and 194 prepectoral). Median age was 43.0 years in both groups, with similar body mass index (22.4 kg/m2 [interquartile range 3.1] versus 22.0 kg/m2 [interquartile range 3.5]; P = 0.795). The overall frequency of secondary procedures at 5 years was comparable (53.1% versus 53.6%; P = 0.650). Pocket revisions were significantly more common following subpectoral reconstruction (9.3% versus 2.6%; P = 0.005), whereas implant exchange rates were not significantly different (7.7% versus 3.1%; P = 0.216). Fat grafting rates were similar (32.5% versus 37.6%; P = 0.338). Overall complication rates did not differ significantly (20.1% versus 22.2%; P = 0.709), and implant loss was low at 5.2% in both groups. CONCLUSIONS: At 5-year follow-up, prepectoral and subpectoral IBR were shown to have comparable rates of secondary aesthetic procedures and postoperative complications. These findings support prepectoral IBR as a safe and effective alternative to subpectoral reconstruction.