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Risks of Reoperation and Implant Loss with Prepectoral Implant-Based Breast Reconstruction: Results of a Seven-Year Cohort
Holly Cordray*1, Salman Khan1, Malia Voytik2, Justus Zemberi1, Gustavo Capone1, Ashley E. Chang1, Robyn B. Broach2, Said Azoury2
1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 2Division of Plastic & Reconstructive Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA

Background: This study evaluated implant-based breast reconstruction trends, anticipating a shift toward prepectoral implants"”instead of subpectoral or dual-plane"”given recent technical advancements. We correlated changes in reconstructive approach with clinical outcomes.

Methods: The cohort included adult patients who received implant-based breast reconstruction at the University of Pennsylvania Health System from 2018-2024. Analyses used linear regression to trend implant plane selection over time, and Chi-square/Fisher's tests with relative risk (RR) to compare postoperative complications by reconstructive approach.

Results: Among 684 patients, all reconstructions were subpectoral (n = 301) or prepectoral (383). Use of prepectoral implants rose significantly across the study period (P = .001), from 4.0% of cases in 2018 to 90.0% in 2024. Prepectoral reconstructions showed significantly lower incidence of postoperative fat necrosis (RR 0.3, 95% CI: 0.1-0.9), nipple-areolar complex necrosis (RR 0.2, CI: 0.1-0.5), and chronic implant-associated pain (RR 0.3, CI: 0.1-0.8). However, prepectoral reconstructions showed significantly higher incidence of surgical site infections (RR 3.3, CI: 2.0-5.4), delayed healing/dehiscence (RR 1.9, CI: 1.3-2.9), tissue expander loss in two-stage reconstructions (RR 2.8, CI: 1.6-4.8), and implant loss (RR 5.0, CI: 1.7-14.1), driving higher rates of reoperation (RR 2.0, CI: 1.5-2.8) and readmission (RR 2.1, CI: 1.2-3.5). Direct-to-implant (vs two-stage) reconstructions showed greater risk of aesthetic revisions (RR 1.9, CI: 1.3-2.7) and specifically prepectoral implant loss (RR 5.8, CI: 2.7-12.3).

Conclusion: Implant plane preference reversed from 2018-2024; prepectoral reconstructions supplanted subpectoral. Despite certain advantages, prepectoral reconstructions showed fivefold risk of implant loss alongside increased risks of infection, delayed healing, and expander loss, ultimately doubling risks of reoperation and readmission. These results warrant further study to determine whether we should reconsider the prepectoral approach.


Figure 1. Postoperative complication rates (A) and re-intervention rates (B) for subpectoral vs prepectoral implants. ***P ≤ .001, **P < .01, *P < .05.
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