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Prepectoral vs. Submuscular Implant-based Breast Reconstruction: A Matched-Pair Comparison of Outcomes
Ankoor A. Talwar1, Michael Lanni1, Isabel Ryan1, Abhishek A. Desai1, Phoebe B. McAuliffe1, Pranav Kodali1, Ellie Bernstein1, Robyn B. Broach1, Paris D. Butler2, Joseph M. Serletti1, Joshua Fosnot1
1 University of Pennsylvania, Philadelphia, PA; 2 Yale Medicine, New Haven, CT

Background: Implant-based breast reconstruction is the most common reconstructive approach following mastectomy. Pre-pectoral implants offer advantages over sub-pectoral implants, such as less animation deformity, pain, weakness, and post-radiation distortion. However, pre-pectoral implants are also associated with complications, namely seroma and infection. Factors that influence complications in pre-pectoral implant-based breast reconstruction need to be ascertained.
Methods: Patients treated with implant-based breast reconstruction following mastectomy at our institution from January 2018 October 2021 were retrospectively reviewed. Both direct-to-implant (DTI) and staged reconstructions were included. Patient and operative factors studied included demographics, comorbidities, history of breast surgery, preoperative cancer therapy, operative factors, and postoperative cancer therapy. Outcomes assessed included surgical site occurrences (e.g. surgical site infection, seroma, etc.), capsular contracture, expander loss, and implant loss. Univariate analyses comparing patient and operative factors with outcomes were done using Chi Square tests. Multivariate analyses were done using backwards stepwise regression.
Results: A total of 707 breasts (392 patients) were included. 200 (28.3%) breasts had prepectoral implants, 437 (61.8%) had total submuscular implants, and 70 (9.9%) had dual plane implants. 101 (14.3%) underwent DTI reconstruction, 606 (85.7%) had staged reconstruction. The mean follow up was 12.0 months. In their postoperative course, prepectoral implants were associated with greater rates of surgical site infection (Prepectoral: 15%, Dual Plane: 12.9%, Submuscular: 3.9%, p<0.05), seroma formation (Prepectoral: 22%, Dual Plane: 14.3%, Submuscular: 11.4%, p<0.05), and implant/expander loss (Prepectoral: 21%, Dual Plane: 11.4%, Submuscular: 4.1%, p<0.05). Multivariate regression revealed the most salient risk factors for infection were a draped coverage pattern over the implant (OR 2.5, p<0.05), for seroma were staged reconstruction (OR 3.8, p<0.05) and having a previous lumpectomy (OR 5.4, p<0.05), and for implant/expander loss was having a prepectoral implant (OR 4.5, p<0.05).
Conclusion: Prepectoral implant-based breast reconstruction is associated with high rates of seroma, infection, and implant/expander loss compared to submuscular and dual plane reconstructions. Various patient and operative factors may affect incidence of complications following this reconstruction. Factors like ADM coverage technique and history of previous breast surgery may play important roles in risk of complications that need to be further understood to plan and optimally counsel patients on reconstructive options.


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