Complications and patient-reported outcomes in breast cancer patients undergoing prepectoral implant-based breast reconstruction: direct-to-implant versus tissue expander-to-implant followed by postmastectomy radiation therapy

Background Optimal implant-based breast reconstruction (IBBR) for patients requiring postmastectomy radiation therapy (PMRT) after prepectoral reconstruction remains unclear. This study compared direct-to-implant (DTI) with tissue expander-to-implant (TEI) reconstruction followed by PMRT, focusing on complications and patient-reported outcomes (PROs). Methods In this single-center retrospective study, breast cancer patients admitted between December 2018 and December 2024 who underwent prepectoral IBBR followed by PMRT were included. Patients received DTI-PMRT (immediate implant plus PMRT) or TEI-PMRT (immediate expander, PMRT, then exchange). Complications, risk factors, reconstruction failure, and BREAST-Q PROs were compared. Results Among 217 patients, 146 completed long-term follow-up. TEI-PMRT had higher crude rates of reconstruction failure (14.5% vs 3.7%; p = 0.008), postoperative infection (13.6% vs 3.7%; p = 0.015), and severe capsular contracture (30.2% vs 14.0%; p = 0.030). TEI remained associated with reconstruction failure after adjustment for surgical approach (OR = 3.71, p = 0.011), but attenuated after mesh adjustment (OR = 2.70, p = 0.076). TEI association with severe contracture ( p = 0.030) attenuated after follow-up adjustment (OR = 1.77, p = 0.248). Postoperative infection was strongly associated with reconstruction failure ( p < 0.001). No significant satisfaction difference was detected; sexual well-being improved within TEI-PMRT after exchange (paired t-test, p < 0.001; Wilcoxon signed-rank, p = 0.001). PRO findings were limited by differential attrition and timing differences. Conclusions In prepectoral IBBR requiring PMRT, TEI-PMRT was associated with higher crude rates of failure and severe contracture than DTI-PMRT, although associations were sensitive to mesh and follow-up adjustment. DTI may be reasonable, but confirmation is required given retrospective design and attrition.