Negative Pressure-Guided Selective ADM Grafting for Upper Medial Contour Refinement in Prepectoral Direct-to-Implant Breast Reconstruction.

BACKGROUND: In prepectoral implant-based breast reconstruction, contour depression of the upper medial pole remains a common aesthetic limitation. This study evaluated whether negative pressure-assisted intraoperative assessment combined with selective acellular dermal matrix (ADM) grafting improves aesthetic outcomes. METHODS: We retrospectively reviewed patients who underwent unilateral prepectoral direct-to-implant reconstruction. Patients were categorized into three groups according to the method of additional ADM graft to the upper medial pole: no additional ADM (Group 1), clinically guided ADM placement (Group 2), and negative pressure-assisted ADM placement (Group 3). Aesthetic outcomes were evaluated using the modified Garbay and Harvard scales by blinded observers. Monotonic trends across ordered groups were analyzed using the Jonckheere-Terpstra test. RESULTS: A total of 81 patients were included. The modified Garbay scores did not differ significantly among groups. Breast shape demonstrated a progressive improvement from Group 1 to Group 3, although this did not reach statistical significance. On the Harvard scale, overall aesthetic scores showed a significant increasing trend from Group 1 through Group 3 (p = 0.023). When analysis was limited to the upper medial pole, a clear stepwise improvement was observed across Groups 1, 2, and 3 (p = 0.003). CONCLUSION: Negative pressure-assisted intraoperative assessment with selective ADM grafting of the upper medial pole was associated with improved contour-specific aesthetic outcomes in prepectoral implant-based breast reconstruction.