190. Complications and Quality of Life in Prepectoral Vs. Subpectoral Breast Reconstruction Following Nipple Sparing Mastectomy

PURPOSE: Prepectoral breast reconstruction has gained popularity as initial concerns related to infection, capsular contracture, and implant extrusion have diminished. Similarly, nipple sparing mastectomy (NSM) has become more common due to improved aesthetics, patient reported outcomes, and comparable rates of complications to skin-sparing techniques. However, it is unknown whether the retained nipple and exposed lactiferous ducts in NSM can act as a portal or nidus for ductal organisms and increase the risk of infection after prepectoral breast reconstruction. The aim of this study was to analyze complication rates, specifically post-operative infection, in patients who underwent a NSM and alloplastic breast reconstruction in a prepectoral vs. submuscular plane. METHODS: A retrospective review was performed of adult female patients who underwent NSM with two-stage alloplastic breast reconstruction from January 2013 to November 2023. Patients were grouped by prepectoral or submuscular implant placement (defined as partial submuscular and complete submuscular). Outcomes of interest included rates of cellulitis, tissue expander or implant loss, seroma, hematoma, and mastectomy skin flap necrosis. BREAST-Q scores assessed patient satisfaction and quality of life after reconstructive surgery. RESULTS: Overall, 693 patients were included; 345 underwent prepectoral reconstruction and 348 underwent submuscular reconstruction. Surgical site infection occurred in 10% of prepectoral patients and 5.7% of submuscular patients (p=0.03). Seroma rates were also higher in patients who underwent prepectoral as compared to submuscular implant placement (15% vs. 6.6%, p<0.001). Multivariable analysis showed that patients with prepectoral implant placement had significantly increased odds of developing surgical site infection and seroma as compared to those with submuscular implant placement (Odds ratio [OR] 1.87, p=0.04 and OR 2.52, p<0.001, respectively). Patients with prepectoral implant placement had significantly higher BREAST-Q physical well-being of the chest scores over time as compared to patients with submuscular implant placement (β = 3.4, p=0.01). CONCLUSIONS: Patients who underwent prepectoral implant placement following NSM have higher risk of surgical site infection and seroma, but have higher physical wellbeing of the chest scores when compared to those who underwent submuscular implant placement following NSM. An increased risk of infection and seroma should be weighed against improved patient-reported outcomes when deciding implant plane placement after NSM.