Prepectoral Breast Reconstruction: Early and Long-term Complications and Outcomes of Total Coverage ADM and Implants vs Polyurethane-Coated Implants Without Use of Acellular Dermal Matrix

Background Immediate prepectoral breast reconstruction (IPBR) has emerged as a prominent alternative to subpectoral techniques, offering favorable outcomes in selected patients. Among available options, implant coverage with acellular dermal matrix (ADM) and the use of polyurethane (PU)-coated implants without ADM represent two widely adopted strategies. Objectives The aim of this study was to examine the comparative efficacy and complication profiles of implant coverage with acellular dermal matrix (ADM) and the use of polyurethane (PU)-coated implants without ADM. Methods This retrospective cohort study included 97 patients (135 breasts) undergoing IPBR following nipple-sparing, skin-sparing, or skin-reducing mastectomy between April 2015 and October 2019. Patients were stratified into two groups: those receiving ADM-covered textured implants and those receiving PU-coated implants. Outcomes assessed included early (<4 weeks), mid-term (>4 weeks), and long-term (≥1 year) complications, as well as aesthetic results evaluated through blinded assessment using a standardized Likert scale. Results PU-coated implants were associated with significantly lower rates of early postoperative seroma (2.9% vs. 33.8%, p<0.001) and infection (1.4% vs. 6.2%). At five years, the incidence of severe capsular contracture (Baker grade 3–4) was markedly higher in the ADM group (47.7% vs. 24.3%, p<0.001), particularly in patients who had not received postmastectomy radiotherapy. No significant differences were observed in the incidence of rippling or step-off deformities. Aesthetic outcomes were superior in the PU group, with significantly better breast symmetry and global aesthetic evaluation (p=0.021). Conclusions PU-coated implants offer a safer and more effective approach in IPBR, with reduced complication rates and improved aesthetic outcomes compared to ADM-covered implants. Patient-specific anatomical and oncologic factors should guide implant selection to optimize surgical outcomes.