Immediate prepectoral versus submuscular breast reconstruction in nipple-sparing mastectomy: a retrospective cohort analysis

Objective: To evaluate early complications in prepectoral breast reconstruction. Methods: A retrospective cohort study including 180 consecutive cases of nipple-sparing mastectomy, comparing immediate breast reconstruction with subpectoral to prepectoral mammary implants in 2012-2022. Clinical and demographic characteristics and complications in the first three months following surgery were compared between the two techniques. Results: The prepectoral technique was used in 22 cases [12.2%] and the subpectoral in 158 [87.8%]. Median age was higher in the prepectoral group [47 versus 43.8 years; p=0.038], as was body mass index [25.1 versus 23.8; p=0.002] and implant volume [447.5 versus 409 cc; p=0.001]. The prepectoral technique was more associated with an inframammary fold [IMF] incision [19 cases, 86.4% versus 85, 53.8%] than with periareolar incisions [3 cases, 13.6% versus 73, 46.2%]; [p=0.004]. All cases in the prepectoral group underwent direct-to-implant reconstruction compared to 54 cases [34.2%] in the subpectoral group. Thirty-eight complications were recorded: 36 [22.8%] in the subpectoral group and 2 [9.1%] in the prepectoral group [p=0.24]. Necrosis of the nipple-areola complex/skin flap occurred in 27 patients [17.1%] in the subpectoral group [prepectoral group: no cases; p=0.04]. The groups were comparable regarding dehiscence, seroma, infection, and hematoma. Reconstruction failed in one case per group [p=0.230]. In the multivariate analysis, IMF incision was associated with the prepectoral group [aOR: 34.72; 95%CI: 2.84-424.63]. Conclusion: The incidence of early complications was comparable between the two techniques and compatible with previous reports. The clinical and demographic characteristics differed between the techniques. Randomized clinical trials are required.