DOI: 10.1093/asj/sjae054 ISSN: 1090-820X

Direct-to-Implant vs Tissue Expander Placement in Immediate Breast Reconstruction: A Prospective Cohort Study

Sarah N Chiang, Alexandra M Keane, Joseph G Ribaudo, Yu Tao, Julie A Margenthaler, Marissa M Tenenbaum, Terence M Myckatyn
  • General Medicine
  • Surgery



Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique.


To compare clinical and patient-reported outcomes of DTI and two-stage tissue expander (TE) reconstruction.


A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction via unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes (PROs) via BREAST-Q were also compared.


A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs, less diabetes, hypertension, and smoking, and smaller breast sizes, and underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, p=0.047), reconstructive failure (5.1% vs 12%, p=0.004), and seroma (3.9% vs 11%, p<0.001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences in adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction.


Prepectoral DTI reconstruction is a viable option for post-mastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications.

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