Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications

Background: Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane. Methods: The authors retrospectively reviewed 348 patients who underwent 536 total immediate, prepectoral implant-based breast reconstructions between January of 2018 and December of 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients who underwent DTI versus TE reconstruction up to 1 year after surgery. Results: Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction (P = 0.1813), respectively. The overall infection rate was 16.4% (n = 57). DTI patients had a significantly greater incidence of wounds (P < 0.0001), including minor (P < 0.0011) and major wounds (P < 0.0053). Significantly greater mastectomy resection weights were found for DTI patients who experienced any complication (P < 0.0076), postoperative wounds (P < 0.0001), and major wounds specifically (P < 0.0035). Compared with medium-thickness acellular dermal matrix (ADM), extra thick ADM was associated with significantly increased rates of infection (P < 0.0408) and wounds (P < 0.0001). Conclusions: Prepectoral DTI reconstruction in patients with adequate flap perfusion may have complication rates comparable to staged TE reconstruction, apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infection and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights who desire comparable or smaller implant volumes.