Prepectoral Direct-to-Implant versus Two-Stage Tissue Expander Breast Reconstruction: Comparison of Aesthetic Outcomes and Revision Procedures
Samantha A. McLaughlin*, Emily R. Finkelstein, Dylan Treger, Sara Danker, Juan Mella- Catenchi, Devinder Singh, Zubin Panthaki, John Oeltjan, Wrood Kassira
Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL
Direct-to-implant (DTI) reconstruction offers numerous benefits over a two-stage tissue expander (TE) approach, including a lower number of surgeries and less time to completion of reconstruction. There is a gap in the current literature assessing if DTI is truly a one-operation procedure, especially in the prepectoral plane. This study will focus on aesthetic outcomes and the rate of elective revision in patients who have undergone prepectoral single-stage DTI and completed two-stage TE reconstruction.
A retrospective review of patients that underwent immediate prepectoral implant-based breast reconstruction with acellular dermal matrix at a single institution between January 2020 to December 2022. Following division of patients based on DTI versus TE reconstruction, the rates of patient-reported and surgeon documented aesthetic concerns and associated revision procedures were determined.
A total of 345 patients underwent either prepectoral DTI (n=169; 49.0%) or TE (n=176; 51.0%). Average patient age was 51.3 years and BMI was 27.1 kg/m2. Reported aesthetic concerns for asymmetry and contour deformities were significantly greater among TE reconstruction (p=0.0007, p=0.0003, respectively). No significant differences were noted for scarring or capsular contracture. The rate of reoperation for any aesthetic revision was significantly greater in the TE cohort (21.6% vs 12.4%; p=0.023). Autologous fat grafting specifically was completed in more patients that underwent TE than DTI (15.3% vs 7.7%; p=0.026). Overall, adjusting for the number of surgeries required for reconstruction type, TE resulted in significantly more additional operations per person (1.26 vs 1.15; p=0.042).
Patients with DTI reconstruction had less documented aesthetic concerns and fewer elective aesthetic revision procedures. DTI in the prepectoral plane may offer patients a single-stage reconstruction option that results in fewer overall surgeries, less time to completion, and better aesthetic outcomes, while also improving patient comfort through avoiding a stiff TE device and serial expansions.
Aesthetic outcomes
| Characteristics | Direct-to-implant group (n=169) | Tissue expander group (n=176) | P-value |
| Aesthetic concerns | |||
| Asymmetry (size, position) | 33 (19.5%) | 63 (35.8%) | 0.0007* |
| Contour deformity (rippling, hollowing, indentation) | 61 (36.1%) | 97 (55.1%) | 0.0003* |
| Scarring | 23 (13.6%) | 31 (17.6%) | 0.3061 |
| Capsular contracture | 19 (11.2%) | 31 (17.6%) | 0.0928 |
| Nipple/areolar complex deformity or displacement | 11 (6.5%) | 16 (9.1%) | 0.3720 |
| Aesthetic revision surgery | |||
| Overall | 21 (12.4%) | 38 (21.6%) | 0.0238* |
| Fat grafting | 13 (7.7%) | 27 (15.3%) | 0.0265* |
| Implant exchange | 9 (5.3%) | 16 (9.1%) | 0.1774 |
| Capsule manipulation | 8 (4.7%) | 14 (8.0%) | 0.2209 |
| Scar revision | 8 (4.7%) | 9 (5.1%) | 0.8705 |
| Autologous flap reconstruction | 3 (1.8%) | 3 (1.7%) | 0.6855 |
*Statistically significant, P < 0.05
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