Comparative outcomes of prepectoral

Background: Robot-assisted surgical techniques are increasingly adopted in breast reconstruction, yet the optimal implant placement approach remains debated. Robot-assisted nipple-sparing mastectomy (RANSM) with immediate prosthetic breast reconstruction using the Da Vinci system has shown improved cosmetic outcomes and patient satisfaction. While prepectoral reconstruction offers easier implant placement and fewer complications, subpectoral reconstruction provides better upper pole contours and reduced acellular dermal matrix (ADM) requirements. This study compared surgical and esthetic outcomes between prepectoral and subpectoral approaches in robot-assisted immediate prosthetic reconstruction. Methods: This single-institute retrospective analysis included patients with breast cancer who underwent RANSM with immediate prosthetic breast reconstruction between October 2021 and May 2024. Seventeen breasts from 10 patients (five prepectoral and five subpectoral cases) were analyzed. Surgical metrics, including operation time, console time, blood loss, hospital stay, and complications, were assessed. Seven independent plastic surgeons graded 1-year postoperative esthetic outcomes using the Harvard/National Surgical Adjuvant Breast and Bowel Project scale. Results: The prepectoral group demonstrated significantly better esthetic outcomes (mean score, 2.42) than those of the subpectoral group (mean score, 3.65; P=0.04). Complication rates were similar between groups, with animation deformities occurring exclusively in the subpectoral group. Subpectoral reconstruction required additional ADM in patients with curved thoracic contours due to muscle injuries. Conclusions: In conclusion, prepectoral reconstruction provides superior esthetics outcomes and eliminates animation deformity, while subpectoral reconstruction may offer enhanced upper pole support. Both methods offer distinct benefits, with patient-specific factors being crucial for optimal approach selection. Larger studies are needed to refine patient selection and outcomes in robot-assisted reconstruction.