Comparison of different implant-based breast reconstruction strategies: A systematic review and Bayesian network meta-analysis

Background: Implant-based breast reconstruction is the most common postmastectomy approach, but the optimal combination of implant plane (prepectoral vs. subpectoral) and timing (immediate vs. delayed) remains controversial. Methods: We systematically searched five databases through March 2025 and included observational studies that compared immediate subpectoral breast reconstruction (ISBR), delayed subpectoral breast reconstruction, immediate prepectoral breast reconstruction (IPBR), and delayed prepectoral breast reconstruction (DPBR). We performed pairwise meta-analyses and Bayesian network meta-analyses (NMA) using R (version 4.4.1). To enhance interpretability, the surface under the cumulative ranking curve (SUCRA) was used to assess the probability that each strategy was the optimal choice for each prespecified outcome. Results: Thirty-one retrospective studies were included. In the NMA, no statistically significant differences were found among the strategies for overall complications, hematoma, or necrosis. Compared with ISBR, IPBR was associated with lower risks of reoperation and wound dehiscence. ISBR was associated with the greatest risk of implant loss. In terms of volume, direct evidence favored DPBR over IPBR, and the SUCRA suggested that delayed strategies are advantageous. No statistically significant differences were observed across the BREAST-Q “satisfaction with breasts,” “sexual well-being” scales, and pain. Conclusions: Across strategies, overall safety is broadly comparable. Prepectoral reconstruction tends to reduce the reoperation rate and capsular contracture rate, whereas subpectoral approaches have fewer constraints regarding flap quality. Delayed reconstruction better supports volume optimization and flexibility, whereas immediate approaches have lower follow-up demands and costs. Surgical planning should integrate flap quality, recovery burden, and patient goals for more individualized treatment selection.