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.