An Algorithmic Approach to Prepectoral Direct-to-Implant Breast Reconstruction: Version 2.0

Background: Prepectoral direct- to- implant breast reconstruction has historically been fraught with complications, including flap necrosis, implant extrusion, and capsular contracture, along with high rates of operative revisions. This may result from a number of factors, including the lack of an algorithmic approach, failure to predict postoperative migration of the implant, use of improper implants, and unsuitable patient selection. Over the past 5 years, the authors have gained significant experience in prepectoral breast reconstruction as they have transitioned their direct- to- implant technique. Methods: Using video, technical aspects for achieving superior results are demonstrated, including suture technique, application of acellular dermal matrix, creation of the implant pocket, implant selection and placement, and postoperative dressings. Video is used to highlight technical aspects to yield consistent, predictable results using the anterior tenting technique. Results: A systematic review of prepectoral direct- to- implant breast reconstruction was conducted to amalgamate the experience of the authors and others with regard to technique, material, and outcomes. Conclusions: Prepectoral direct- to- implant breast reconstruction represents a significant paradigm shift in postmastectomy breast reconstruction and warrants reconsideration. Prepectoral direct- to- implant breast reconstruction provides the potential benefits of a single- stage operation, elimination of dynamic deformity, enhanced aesthetic outcomes, and increased patient satisfaction. Although early evidence suggests an increased incidence of complications, our experience and that of others demonstrate favorable outcomes with version 2.0 of prepectoral direct- to- implant breast reconstruction. As the body of literature encompassing a modern approach to prepectoral direct- to- implant breast reconstruction grows, greater appreciation for operative technique, candidate selection, and implant choice may accelerate its adoption and mitigate past concerns.