# Considering Factors for Deciding Between Subpectoral and Prepectoral Planes in Direct-to-Implant Breast Reconstruction

## TL;DR

This study compares two surgical approaches for breast reconstruction to determine which leads to better patient satisfaction and fewer complications.

## Contribution

The study provides principles for selecting between subpectoral and prepectoral planes in direct-to-implant breast reconstruction based on defect dimensions and outcomes.

## Key findings

- The prepectoral plane became more commonly used after 2020 compared to the subpectoral plane.
- Patients in the prepectoral group reported higher overall satisfaction scores than those in the subpectoral group.
- Selecting the surgical plane based on defect dimensions reduces complications and improves patient satisfaction.

## Abstract

Background/Objectives: Considering the increasing importance placed on the quality of life among those who survive cancer, breast reconstruction is no longer limited to only compensating for breast loss; achieving the patient’s preferences is now considered. However, the optimal surgical approach (subpectoral plane vs. prepectoral plane) in single-stage direct-to-implant breast reconstruction (DTIBR) has not been established. The aim of this study was to summarize the principles for selecting between the subpectoral and prepectoral planes in DTIBR. Methods: In this retrospective study, we evaluated 543 patients with breast cancer who underwent DTIBR between March 2018 and October 2025. Postmastectomy reconstruction was performed in the subpectoral plane when the defect showed greater breast height than width, whereas the prepectoral plane was used when breast width exceeded height. Complications requiring reoperation were analyzed. Patient satisfaction was evaluated based on overall satisfaction, esthetic outcome, physical symptoms, psychosocial impact, and decision satisfaction using a visual analog scale. Results: The subpectoral dual-plane approach was most commonly used between 2018 and 2019, while the prepectoral plane became predominant after 2020. Overall, 83 (14.4%) patients developed major complications. The overall satisfaction score was 4.1 ± 0.80 in the subpectoral group and 4.35 ± 0.70 in the prepectoral group, showing a statistically significant difference (p value = 0.012). Conclusions: The subpectoral and prepectoral planes have distinct advantages and limitations. Ultimately, the reconstructive surgeon should determine the most appropriate option in DTIBR. Selecting the surgical plane based on the postmastectomy defect reduces complications while improving patient satisfaction.