Discussion: Prepectoral versus Subpectoral Implant-Based Breast Reconstruction: Evaluating the Shift

Be not the first by whom the new are tried, nor yet the last to lay the old aside. —Alexander Pope Over the past decade, the popularity of prepectoral breast reconstruction has increased exponentially.1 For the prior 40-plus years, submuscular breast reconstruction using a 2-stage technique had been standard, often with excellent results. However, patients did complain of animation deformity, and some experienced chronic implant-related pain. Plastic surgeons sought to mitigate these issues by altering the plane of reconstruction. Placing the tissue expander or implant above the muscle would eliminate the animation deformity and perhaps reduce the long-term discomfort of the implant. Multiple studies of prepectoral reconstructions have borne out this good news and demonstrated improvement in patient-reported quality of life.2–4 King et al. reported decreased ischemic complications, such as mastectomy skin flap necrosis or loss of the nipple areola complex, in their prepectoral reconstructions. Reoperation rates in their prepectoral and subpectoral cohorts were similar.4 Wang et al. did show an almost doubled risk of surgical-site infections (10% versus 5.7%) and a more than doubled risk of seroma (15% versus 6.6%) in their population of prepectoral versus subpectoral reconstructions, but no other significant complications.2 However, showing that it is not always sunny in Philadelphia, Cordray et al. report on their experience with prepectoral breast reconstruction.1 Over the course of this study period, 8 University of Pennsylvania plastic surgeons evolved to make prepectoral reconstruction the “default choice” at their institution. Their rate of prepectoral reconstructions shifted from 4% of patients in 2018 to 90.2% by 2024. In this thorough evaluation of their results, they show that although their prepectoral patients did have reduced rates of fat necrosis, nipple areola complex necrosis, and chronic pain, they did not see a difference in mastectomy skin flap necrosis rates. Whereas their prepectoral patients did report an improved sense of well-being postoperatively, the authors were disturbed to find a 3-fold increase in the risk of surgical-site infection and a 2-fold increase in delayed healing/wound dehiscence. Their prepectoral patients were more likely to be readmitted to the hospital postoperatively, and had a 20% risk for reoperation because of threatened implant loss. The incidence of “true failure” (removal of the tissue expander/implant with flat closure) was 11.2% in their prepectoral cohort and 4% in the subpectoral group. Their rate of complications over this 8-year period did not improve, thus disabusing the idea that a “learning curve” might be at issue. This study also pointed out the increased risks associated with direct-to-implant reconstruction in either the prepectoral or subpectoral plane, with delayed healing and reoperation rates being significantly higher, and doubling the need for a revision for aesthetic reasons. These authors note that more than 95% of their prepectoral reconstructions included the use of acellular dermal matrix (ADM). Because of the much smaller number of prepectoral reconstructions without ADM, they were unable to compare results of the ADM versus non-ADM patients. Bassi et al. have reported on their cohort of non-ADM prepectoral direct-to-implant reconstructions and demonstrated a reoperation rate only slightly higher than that of their subpectoral plane patients.3 Further study regarding ADM’s contribution to the reoperation risk is warranted. Prepectoral breast reconstruction is here to stay; however, there are still some kinks to be worked out. Honestly reporting complications, as this study has done, followed by thoughtful consideration and vetting of solutions, is critical. In our enthusiasm to provide women with a less painful implant-based breast reconstruction that does not jump around with pectoral motion, we must remember to appropriately counsel our patients. Every woman considering prepectoral breast reconstruction must be fully informed of her risk of complications, including the nonnegligible possibility of reoperation and the risk of true failure. DISCLOSURE The author has no financial disclosures to report.