American Association of Plastic Surgeons

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A Closer Look To Prepectoral Implant-based Breast Reconstruction: A Matched-pair Comparison Of Direct-to-implant Versus Conventional Two-staged Outcomes
Chris Amro, MD, Jane N. Ewing, BS, Zachary Gala, MD, Mehdi S. Lemdani, BA, Ankoor A. Talwar, MBA, Isabel A. Ryan, BS, Robyn B. Broach, PhD, Joshua Fosnot, MD, Joseph M. Serletti, MD, John P. Fischer, MD, MPH.
University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Direct-to-implant (DTI) reconstruction offers several advantages over the two-stage implant-based breast reconstruction approach. However, the outcomes of prepectoral reconstruction are debated. Many prior studies contained confounders, making their conclusions less definitive. Our study offers the first matched cohort analysis comparing DTI versus two-stage reconstruction in the prepectoral plane.
METHODS: Patients treated with implant-based breast reconstruction post-mastectomy from 2018-2021 were retrospectively reviewed. Patients were propensity score matched by BMI, smoking status, history of hypertension, mastectomy type, chemotherapy, radiotherapy, ADM use and coverage type. Outcomes assessed included surgical site occurrences (SSO), capsular contracture, and explantation of either expander or implant.
RESULTS: A total of 433 breasts were identified; 154 breasts were matched (77 DTI:77 Two-staged). Two-staged prepectoral reconstruction were associated with greater rates of seromas (Two-staged: 18.2%, DTI: 5.2%, p<0.05) , and overall SSOs (Two-staged: 45.5%, DTI: 24.7%, p=<0.05). This approach was also an independent predictor on multivariate regression (AOR: 4.86, p<0.05). There were no differences between the groups regarding final implant size, loss of sensation, capsular contraction (Grades III or IV), or implant/expander loss (p>0.05). There were also no significant differences in secondary reconstruction and failures of secondary reconstructions after explantation between both groups with a mean follow up of 22 months.
CONCLUSION: Prepectoral two-staged reconstruction is associated with higher rates of seromas and overall surgical site occurrences compared to DTI reconstruction. Secondary reconstruction following explantation can readily achieve long-term success in both cohorts. Prepectoral DTI reconstruction is encouraged due to fewer surgeries, reduced risks, and minimized patient burden.
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