Is Prepectoral Implant Reconstruction Associated With Better Physical Well-Being?

Background: Improvements in mastectomy techniques, implants, and devices for implant support have enabled a resurgence in prepectoral implant reconstruction. One of the drivers of this shift is a perception among patients and physicians that retropectoral implants cause more physical morbidity. Although studies have shown more rapid early recovery among patients who undergo prepectoral reconstruction, little is known about whether this approach improves long-term physical outcomes.

Methods: A prospectively maintained database was used to identify patients who underwent immediate implant-based postmastectomy reconstruction from October 2017 to March 2020. Patients who underwent radiation treatment or who failed to complete implant reconstruction were excluded. Demographic and clinical characteristics, including postoperative complications, were analyzed. BREAST-Q surveys were sent to patients 12-24 months following the completion of reconstruction. Bivariate independent t-test and chi-square analysis were used to compare prepectoral and retropectoral cohorts.

Results: 168 patients were identified. 78 (46.4%) completed questionnaires and met the inclusion criteria for the study. 33 patients had subpectoral implants and 45 patients had prepectoral implants. Nonresponders had a similar proportion of implant positions to responders (p = 0.32). The median time between mastectomy and completion of the BREAST-Q survey was 21 months (IQR, 20-23 months). Patients with subpectoral reconstruction were older (56 ± 13 vs. 50 ± 13 years, p = 0.048) and had higher BMIs (27.8 ± 7.3 vs. 24.2 ± 3.8 kg/m², p = 0.012) and were less likely to have undergone direct-to-implant reconstruction (18.2% vs. 51.5%, p = 0.003). There were no other significant clinical or demographic differences between groups. BREAST-Q chest well-being data showed no significant difference in long-term chest wall morbidity among retropectoral and prepectoral cohorts.

Conclusions: For many patients, prepectoral reconstruction confers esthetic benefits, including better projection and more stable implant and nipple position. However, there remain patients for whom a retropectoral approach is more suitable due to the risks of rippling and implant visibility. Surgical decision-making should continue to be individualized according to anatomic and disease-specific factors as well as surgeon and patient preference. However, patients should be reassured that their long-term physical well-being is unlikely to be affected by which technique is chosen.