Revisiting Total Subpectoral Breast Reconstruction: Technical Refinements for Improved Outcomes.

Background: Although prepectoral direct-to-implant breast reconstruction has gained increasing popularity, it is not suitable for all patients. Subpectoral reconstruction remains necessary in selected cases, yet traditional techniques are limited by animation deformity and restricted lower-pole expansion. Objectives: The aim of this study was to evaluate the safety, reproducibility, and clinical outcomes of a refined, mesh-free total subpectoral reconstruction technique. Methods: A retrospective analysis was performed on 119 patients (181 breasts) undergoing immediate implant-based reconstruction using a standardized subpectoral technique. Key anatomical structures-including the inframammary ligament, serratus anterior fascia, and intercostal perforators-were preserved. Controlled fascial releases and limited superior dissection were employed to optimize implant positioning and lower-pole expansion. Outcomes included complication rates, revision surgery, and BREAST-Q scores. Results: The mean follow-up was 28.1 months. Minor complications occurred in 28.6% of cases, whereas major complications were observed in 6.7%. Hematoma, infection, and implant-related complications remained within the lower range of reported literature values. Revision surgery was required in 7.6% of patients, primarily because of contour irregularities, all successfully managed with single-stage correction. Among 100 patients completing BREAST-Q assessment, the mean score was 76.6 ± 15.1. Conclusions: This refined mesh-free total subpectoral technique provides stable implant positioning, improved lower-pole projection, and reduced animation deformity. In appropriately selected patients, it represents a safe, reproducible, and cost-effective alternative to conventional submuscular approaches. Level of Evidence 4 Therapeutic: For image description, please refer to the figure legend and surrounding text.