Prepectoral and subpectoral direct-to-implant breast reconstruction yield high cosmetic scores: Surgeon ratings favor prepectoral placement-secondary results from a randomized controlled trial.

Background: Direct-to-implant (DTI) breast reconstruction is increasingly used following mastectomy, with implants placed in a subpectoral or prepectoral plane. While subpectoral placement has been the conventional approach, prepectoral reconstruction is gaining popularity due to reduced risk of breast animation deformity (BAD) and potentially improved patient comfort. However, comparative data on cosmetic outcomes remain limited. Objectives: To compare patient- and surgeon-reported cosmetic outcomes following prepectoral and subpectoral DTI breast reconstruction as a secondary analysis of a randomized controlled trial. Methods: Forty-two patients undergoing post-mastectomy DTI breast reconstruction were randomized to receive either subpectoral or prepectoral implant placement. Cosmetic outcomes were evaluated using a 10-point numeric rating scale (NRS) by both patients and two consultants in plastic surgery at 3 and 12 months postoperatively. Data were analyzed using independent t-test. Results: A total of 60 breasts were reconstructed: 27 subpectoral and 33 prepectoral. At 3 months, patient NRS scores were 8.0 ± 1.9 (subpectoral) vs. 8.5 ± 1.9 (prepectoral) ( Conclusion: Cosmetic satisfaction was high in both groups at any given time point. While patient ratings were comparable, surgeons evaluated prepectoral implant placement superior at 12 months. These findings support prepectoral DTI reconstruction as a cosmetically favorable option in eligible patients.