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Direct-to-Implant in the Era of Prepectoral Breast Reconstruction: Evaluation of the National Trend in 59,313 Patients

Year: 2025

Type: article

Abstract: Implant-based postmastectomy breast reconstruction is more common than autologous reconstruction.1 Implant reconstruction may be performed either immediate-delayed or direct-to-implant (DTI) immediately following mastectomy.2 Recently, there has been a shifting trend in favor of prepectoral implant-based reconstruction over subpectoral reconstruction.3 Although there are several benefits to prepectoral reconstruction, superior pole deficiency and visible implant rippling typically are more pronounced compared with subpectoral reconstruction and often require fat grafting for correction during a second stage.4 A major advantage of DTI over tissue expander (TE) reconstruction is the potential for a “single-stage” reconstruction at the potential risk of greater tension on the skin flaps.2 The trend of DTI has not been well characterized during the recent rise of prepectoral reconstruction. Considering prepectoral reconstruction frequently benefits from a second stage of fat grafting, the purpose of this study is to evaluate the national trend of DTI reconstruction compared with TE reconstruction, which always requires a second stage. The American College of Surgeons-National Surgical Quality Improvement Program database (2010–2022) was analyzed for patients who had mastectomy (Current Procedural Terminology [CPT] 19303, 19307). Patients who underwent either immediate TE (CPT 19357) or implant reconstruction (CPT 19340) on the same day were included. Those who received implants with breast free flap (CPT 19364) or pedicled latissimus flap (CPT 19361) reconstruction were excluded. Patients were divided into 2 groups: group 1 (mastectomy with DTI reconstruction) and group 2 (mastectomy with immediate TE reconstruction). Demographic information, comorbidities, mastectomy laterality, and yearly case volume were recorded. The study included 59,313 patients. Group 1 had 9847 patients, and group 2 had 49,466 patients. The average body mass index was 26.8 ± 5.9 kg/m2 in group 1 compared with 28.0 ± 6.4 kg/m2 in group 2 (P = 0.001) (Table 1). Smoking was present in 7.2% (706 of 9847) of group 1 compared with 9.9% (4889 of 49,466) of group 2 (P = 0.0001). Unilateral mastectomy was performed in 63.0% (6208 of 9847) of group 1 compared with 61.2% (30,265 of 49,466) of group 2 (P = 0.001). The case volume for DTI reconstruction in 2010 was 9.1% (225 of 2474) compared with 21.4% in 2022 (1159 of 5427) (P = 0.0001). Although, there was an insignificant volume dip in DTI in 2020 (20.2%, 1093 of 5412) compared with 2019 (21.6%, 1172 of 5413) (P = 0.0626), there was a trend for the frequency of DTI increasing annually (Table 2). Table 1. - Baseline Characteristics Variables Group 1, DTI (n = 9847) Group 2, TE (n = 49,466) P Average age (y) 35.9 ± 10.4 35.7 ± 10.0 0.014 Body mass index (kg/m2) 26.8 ± 5.9 28.0 ± 6.4 0.001 Diabetes mellitus 549 (5.6%) 3199 (6.5%) 0.0009 Active smoker 706 (7.2%) 4889 (9.9%) 0.0001 Bilateral mastectomy 3639 (37.0%) 19,201 (38.8%) 0.001 Unilateral mastectomy 6208 (63.0%) 30,265 (61.2%) 0.001 Table 2. - Annual Frequency of TE Reconstruction and DTI Reconstruction Years 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Total N 2474 2528 3455 4133 3045 4459 5326 5509 5365 5413 5412 5732 5427 59,313 TE 2249 (90.9%) 2246 (88.8%) 2983 (86.3%) 3485 (84.7%) 3453 (87.5%) 3866 (86.7%) 4528 (86.5%) 4702 (85.4%) 4392 (81.8%) 4241 (78.3%) 4319 (79.8%) 4519 (78.8%) 4268 (78.6%) 49,466 DTI 225 (9.1%) 282 (11.2%) 472 (13.7%) 628 (15.3%) 492 (12.5%) 593 (13.3%) 708 (13.5%) 807 (14.6%) 973 (18.1%) 1172 (21.6%) 1093 (20.2%) 1213 (21.2%) 1159 (21.4%) 9847 Despite a shift in plastic surgeons performing prepectoral breast reconstruction, the rates of DTI reconstruction have trended to increase annually on a national scale.5 In our study, we found an insignificant drop in DTI frequency in 2020 compared with 2019, which may have been confounded by COVID-19. The study is limited by the lack of a distinct CPT code for planes of reconstruction. It is not feasible to determine the precise number of prepectoral reconstructions in the American College of Surgeons-National Surgical Quality Improvement Program database. However, a survey study in 2020 indicated that 48.4% of plastic surgeons primarily performed prepectoral reconstruction.3 Breast revisions are common.6 Patients should be counseled that a second stage is likely after prepectoral DTI. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Source: Plastic & Reconstructive Surgery Global Open

DOI: 10.1097/gox.0000000000006633