Complications and Patient-Reported Outcomes in Prepectoral vs Submuscular Breast Reconstruction Following Nipple Sparing Mastectomy

Background: Preprectoral breast reconstruction and nipple-sparing mastectomy (NSM) have both risen in popularity due to advances in reconstructive techniques. However, it is unknown whether exposed lactiferous ducts in a NSM may increase the risk for infection after prepectoral implant-based breast reconstruction. We aimed to assess complication rates and BREAST-Q Physical Well-Being of the Chest (PWBC) scores in patients who underwent NSM and implant-based breast reconstruction in a prepectoral vs. submuscular plane. Methods: A retrospective review was performed of patients who underwent NSM with two-stage implant-based reconstruction from 2013-2023. Patients were grouped by prepectoral or submuscular placement. Post-operative complications and BREAST-Q scores were assessed after surgery. Results: 693 patients were included; 345 underwent prepectoral and 348 underwent submuscular reconstruction. Surgical site infection occurred in 10% of prepectoral patients and 5.7% of submuscular patients (p=0.03). Seroma occurred in 15% of prepectoral patients and 6.6% submuscular patients (p<0.001). Multivariable analysis showed prepectoral patients had significantly increased odds of developing surgical site infection and seroma compared to submuscular patients (Odds ratio [OR] 1.87, p=0.04 and OR 2.52, p<0.001, respectively). However, prepectoral reconstruction was associated with significantly higher BREAST-Q PWBC scores as compared to submuscular implant placement (β=3.4, p=0.01). Conclusions: Prepectoral reconstruction following NSM is associated with higher rates of surgical site infection and seroma but improved physical well-being of the chest compared to submuscular implant placement following NSM. An increased risk of infection and seroma should be weighed against improved patient-reported outcomes when deciding on implant plane placement after NSM.