Advocating for optimal surgical approaches in prepectoral implant breast reconstruction

Introduction

The development of acellular dermal matrix (ADM) devices has significantly enhanced implant-based breast reconstruction (IBBR) following conservative mastectomy, whether for therapeutic or risk-reducing purposes, often yielding improved aesthetic outcomes. Traditionally, the subpectoral approach involves placing the implant beneath the pectoralis major muscle, with ADM used for inferior coverage. However, to eliminate breast animation, reduce postoperative pain, and decrease capsular contracture risk, there has been a shift towards the prepectoral approach, in which the implant is positioned above the muscle and fully enveloped by ADM (1). It should be noted that ADM use in breast reconstruction remains off-label, as the Food and Drug Administration (FDA) has not yet approved it for this indication.

Evaluation of current evidence

Harvey et al. recently reported patient-reported outcomes (PROs) at 3 and 18 months following mastectomy and immediate prepectoral implant-based reconstruction as part of the UK Pre-BRA prospective multicenter study (2). Although the study provides valuable insight, several methodological limitations affect the applicability of its findings.

A major concern is the heterogeneity in surgical techniques, including variation in ADM use and the distinction between single-stage and two-stage reconstruction. These inconsistencies impact outcome interpretation and reduce the generalizability of the conclusions. Notably, patients who did not receive ADM may have experienced higher rates of complications such as implant rippling, which ADM has been shown to mitigate, leading to superior cosmetic outcomes and greater patient satisfaction.

Although no randomized controlled trials (RCTs) have assessed ADM’s role in prepectoral reconstruction, its use in subpectoral implant placement has been evaluated. Lohmander et al. conducted an RCT comparing subpectoral IBBR with and without ADM and found that ADM use was associated with improved patient satisfaction in selected domains (3). Specifically, patients who received ADM reported better overall aesthetic satisfaction [mean difference 8.66; 95% confidence interval (CI): 0.46 to 16.86; P=0.041] and fewer difficulties with bra fitting (mean difference −13.21; 95% CI: −25.54 to −0.89; P=0.038). However, these findings cannot be extrapolated to prepectoral reconstruction due to anatomical and technical differences.

Furthermore, subpectoral placement offers an additional muscle layer that can reduce the incidence of rippling, potentially minimizing the need for adjunctive fat grafting. Although a recent systematic review found no significant differences in major complications between ADM use and non-use in prepectoral reconstruction, ADM use was associated with lower rates of wound dehiscence, capsular contracture, and rippling. The risk ratios for these complications were 0.61, 0.31, and 0.55, respectively (4).

Synthetic and non-biologic mesh alternatives have also shown comparable results in selected patients. These options may offer advantages in terms of cost-effectiveness and accessibility, particularly in resource-limited healthcare settings. The decision to use ADM must be weighed against these factors when formulating individualized reconstructive plans.

Institutional experience and technique optimization

In our prospective series of 72 single-stage ADM-assisted prepectoral reconstructions following nipple-sparing mastectomy, we observed a low complication rate of 2.8%, with no implant losses and minimal rippling requiring intervention at a mean follow-up of 18.3 months (5). Most patients were non-obese, had small to moderate breast volumes, and did not undergo radiation therapy. All reconstructions were performed using smooth, cohesive gel silicone implants (170–450 cc) with full ADM coverage (Figure 1).

Figure 1 Postoperative image of a 45-year-old patient at 6 months following single-stage bilateral nipple-sparing mastectomy and immediate implant-based reconstruction. Smooth, cohesive gel silicone implants (220 cc; Motiva SilkSurface) were used. ADM (exaSHAPE, Medis Medical Imaging Systems B.V., Amsterdam, The Netherlands) provided full anterior implant coverage. Incisions were placed circumferentially around the superior areolar margins. No radiotherapy was administered. The procedure was performed for risk reduction in a BRCA1 mutation carrier. The image is published with the patient/participant’s consent. ADM, acellular dermal matrix.

Although promising, these results reflect a carefully selected cohort managed by experienced surgeons using standardized techniques. The lack of a control group and objective aesthetic evaluation limits generalizability.

To address implant contour irregularities such as rippling, Vidya et al. proposed a four-tier grading system (grades 1–4) to standardize assessments and inform the use of adjunctive fat grafting (6). We observed that thin skin flaps and low subcutaneous fat thickness correlated with increased rippling risk, which was effectively mitigated by ADM combined with cohesive gel implants. In patients with moderate rippling, lipomodelling was selectively employed with satisfactory results.

Need for standardization and comparative research

Future studies should adopt standardized surgical protocols, particularly for single-stage ADM-assisted prepectoral reconstruction, and stratify outcomes by factors such as radiation exposure, body mass index, and mastectomy weight. Objective evaluation tools, including validated PROs and rippling scores, should be used to assess aesthetic results.

There is an urgent need for high-quality comparative studies, including RCTs, in the prepectoral setting to accurately define ADM’s utility and safety. Until such data are available, its use should be individualized based on patient anatomy, oncologic factors, and surgeon experience. Clinicians must remain cognizant of potential complications, including infection, seroma, red breast syndrome, capsular contracture, wound dehiscence, and rippling.

Conclusions

While the UK Pre-BRA study offers valuable prospective data, its interpretation is hindered by heterogeneity in surgical techniques and patient selection. There is a clear need for RCTs specifically evaluating ADM use in prepectoral reconstruction to develop standardized guidelines. In the interim, selective use of ADM, tailored to patient and institutional factors, remains a rational strategy. Consideration of alternative meshes and adherence to technique optimization are essential for achieving consistent, aesthetically favorable outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-87/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-87/coif). K.M. has received honoraria for offering academic and clinical advice to Merit Medical and QMedical corporations. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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