Prepectoral versus Subpectoral Dual-Plane Direct-to-Implant Breast Reconstruction with the TiLoop Bra: A Single-Center Prospective Cohort Study

BACKGROUND: Advancements in surgical techniques and materials have increased the use of direct-to-implant breast reconstruction after mastectomy. However, the optimal implant placement remains debated, with limited prospective studies comparing prepectoral and subpectoral dual-plane reconstruction using titanium-coated polypropylene mesh. METHODS: A prospective cohort study was conducted from June of 2021 to December of 2023 at a single center, analyzing postoperative pain, complications, aesthetic outcomes, and patient-reported outcomes in patients undergoing unilateral prepectoral or subpectoral dual-plane reconstruction. RESULTS: Ninety-four patients were included, with 50 in the prepectoral group and 44 in the subpectoral group. The subpectoral group experienced higher postoperative pain and greater analgesic use during the first 14 days. Animation deformity and pectoralis major muscle pain were avoided in the prepectoral group, whereas capsular contracture was more frequent in the subpectoral group. Implant outline visibility was higher in the prepectoral group. Aesthetic assessment showed superior results for the prepectoral group, and patients reported greater satisfaction with their breasts and physical well-being at 12 and 24 months. CONCLUSION: Prepectoral reconstruction reduces certain complications, aligns better with physiologic anatomy, and improves patient satisfaction and quality of life, although it requires a high-quality flap, highlighting the importance of careful patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.