Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes

Published:October 18, 2022DOI:


      Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR.


      A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented.


      After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p > 0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p = 0.001). The intraoperative expansion volumes were higher in the prepectoral group (300 ml versus 200 ml, p = 0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p = 0.58).


      Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Albornoz C.R.
        • Bach P.B.
        • Mehrara B.J.
        • et al.
        A paradigm shift in U.S. Breast reconstruction: increasing implant rates.
        Plast Reconstr Surg. 2013; 131: 15-23
        • Weissler J.M.
        • Banuelos J.
        • Jacobson S.R.
        • et al.
        Intravenous tranexamic acid in implant-based breast reconstruction safely reduces hematoma without thromboembolic events.
        Plast Reconstr Surg. 2020; 146: 238-245
        • Kraenzlin F.S.
        • Darrach H.
        • Chopra K.
        • Rosson G.D.
        • Broderick K.P.
        • Sacks J.M.
        Prepectoral 2-stage breast reconstruction with carbon dioxide tissue expansion.
        Plast Reconstr Surgery Glob Open. 2020; 8: e2850
        • Manrique O.J.
        • Kapoor T.
        • Banuelos J.
        • et al.
        Single-stage direct-to-implant breast reconstruction: a comparison between subpectoral versus prepectoral implant placement.
        Ann Plast Surg. 2020; 84: 361-365
        • Li Y.
        • Xu G.
        • Yu N.
        • Huang J.
        • Long X.
        Prepectoral versus subpectoral implant-based breast reconstruction: a meta-analysis.
        Ann Plast Surg. 2020; 85: 437-447
        • Ching A.H.
        • Lim K.
        • Sze P.W.
        • Ooi A.
        Quality of life, pain of prepectoral and subpectoral implant-based breast reconstruction with a discussion on cost: a systematic review and meta-analysis.
        J Plast Reconstr Aesthetic Surg. 2022;
        • Li L.
        • Su Y.
        • Xiu B.
        • et al.
        Comparison of prepectoral and subpectoral breast reconstruction after mastectomies: a systematic review and meta analysis.
        Eur J Surg Oncol. 2019; 45: 1542-1550
        • Nahabedian M.Y.
        Current approaches to prepectoral breast reconstruction.
        Plast Reconstr Surg. 2018; 142
        • Sbitany H.
        • Piper M.
        • Lentz R.
        Prepectoral breast reconstruction: a safe alternative to submuscular prosthetic reconstruction following nipple-sparing mastectomy.
        Plast Reconstr Surg. 2017; 140
        • Woo A.
        • Harless C.
        • Jacobson S.R.
        Revisiting an old place: single-surgeon experience on post-mastectomy subcutaneous implant-based breast reconstruction.
        Breast J. 2017; 23: 545-553
        • Nelson J.A.
        • Shamsunder M.G.
        • Vorstenbosch J.
        • et al.
        Prepectoral and subpectoral tissue expander-based breast reconstruction: a propensity-matched analysis of 90-day clinical and health-related quality-of-life outcomes.
        Plast Reconstr Surg. 2022; 149: 607e-616e
        • Xie J.
        • Wang M.
        • Cao Y.
        • et al.
        ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a meta-analysis.
        J Plast Surg Hand Surg. 2021; 0: 1-9
        • Momeni A.
        • Remington A.C.
        • Wan D.C.
        • Nguyen D.
        • Gurtner G.C.
        A matched-pair analysis of prepectoral with subpectoral breast reconstruction: is there a difference in postoperative complication rate?.
        Plast Reconstr Surg. 2019; 144: 801-807
        • Schaeffer C.V.
        • Dassoulas K.R.
        • Thuman J.
        • Campbell C.A.
        Early functional outcomes after prepectoral breast reconstruction: a case-matched cohort study.
        Ann Plast Surg. 2019; 82
        • Sbitany H.
        • Sandeen S.N.
        • Amalfi A.N.
        • Davenport M.S.
        • Langstein H.N.
        Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.
        Plast Reconstr Surg. 2009; 124: 1735-1740
        • Manrique O.J.
        • Charafeddine A.
        • Abu-Ghname A.
        • et al.
        Two-staged implant-based breast reconstruction: a long-term outcome study in a young population.
        Medicina. 2019; 55 (Kaunas)
        • Manrique O.J.
        • Banuelos J.
        • Abu-Ghname A.
        • et al.
        Surgical outcomes of prepectoral versus subpectoral implant-based breast reconstruction in young women.
        Plast Reconstr Surg Glob Open. 2019; 7: 1-5
      1. R Core Development Team. R Core Team (2021). R: A language and environment for statistical computing. (Version 4.0) [Computer Software]. Retrieved from Published online 2021.

        • Collier W.
        • Scheefer Van Boerum M.
        • Kim J.
        • Kwok A.C.
        Are 30-day outcomes enough? Late infectious readmissions following prosthetic-based breast reconstruction.
        Plast Reconstr Surg. 2019; 144: 360e-368e
        • Haddock N.T.
        • Kadakia Y.
        • Liu Y.
        • Teotia S.S.
        Prepectoral versus subpectoral tissue expander breast reconstruction: a historically controlled, propensity score-matched comparison of perioperative outcomes.
        Plast Reconstr Surg. 2021; 148: 1-9
        • Abbate O.
        • Rosado N.
        • Sobti N.
        • Vieira B.L.
        • Liao E.C.
        Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes.
        Breast Cancer Res Treat. 2020; 182: 543-554
        • Tomita K.
        • Yano K.
        • Nishibayashi A.
        • Hosokawa K.
        Effects of subcutaneous versus submuscular tissue expander placement on breast capsule formation.
        Plast Reconstr Surg Glob Open. 2015; 3
        • Walia G.S.
        • Aston J.
        • Bello R.
        • et al.
        Prepectoral versus subpectoral tissue expander placement: a clinical and quality of life outcomes study.
        Plast Reconstr Surg Glob Open. 2018; 6
        • Sbitany H.
        • Langstein H.N.
        Acellular dermal matrix in primary breast reconstruction.
        Aesthetic Surg J. 2011; 31 (30S-7S)
        • Manrique O.J.
        • Huang T.C.T.
        • Martinez-Jorge J.
        • et al.
        Prepectoral two-stage implant-based breast reconstruction with and without acellular dermal matrix: do we see a difference?.
        Plast Reconstr Surg. 2020; 145: 263e-272e
        • Crosby M.A.
        • Dong W.
        • Feng L.
        • Kronowitz S.J.
        Effect of intraoperative saline fill volume on perioperative outcomes in tissue expander breast reconstruction.
        Plast Reconstr Surg. 2011; 127: 1065-1072
        • Yalanis G.C.
        • Nag S.
        • Georgek J.R.
        • et al.
        Mastectomy weight and tissue expander volume predict necrosis and increased costs associated with breast reconstruction.
        Plast Reconstr Surg Glob Open. 2015; 3: 1-9
        • Li Q.
        • Zan T.
        • Li H.
        • et al.
        Flap prefabrication and stem cell-assisted tissue expansion: how we acquire a monoblock flap for full face resurfacing.
        J Craniofac Surg. 2014; 25: 21-25
        • Wormer B.A.
        • Valmadrid A.C.
        • Ganesh Kumar N.
        • et al.
        Reducing expansion visits in immediate implant-based breast reconstruction: a comparative study of prepectoral and subpectoral expander placement.
        Plast Reconstr Surg. 2019; 144
        • Plachinski S.J.
        • Boehm L.M.
        • Adamson K.A.
        • LoGiudice J.A.
        • Doren E.L.
        Comparative analysis of prepectoral versus subpectoral implant-based breast reconstruction.
        Plast Reconstr Surg Glob Open. 2021; 9: e3709
        • Sinnott C.J.
        • Persing S.M.
        • Pronovost M.
        • Hodyl C.
        • McConnell D.
        • Ott Young A.
        Impact of postmastectomy radiation therapy in prepectoral versus subpectoral implant-based breast reconstruction.
        Ann Surg Oncol. 2018; 25: 2899-2908
        • Nahabedian M.Y.
        • Cocilovo C.
        Two-stage prosthetic breast reconstruction: a comparison between prepectoral and partial subpectoral techniques.
        Plast Reconstr Surg. 2017; 140: 22S-30S