Skin-Reducing Mastectomy and Submuscular Expander: A Preliminary Study on Patient-Reported Outcomes

Background: Immediate implant-based reconstruction in large and ptotic breasts represents a significant surgical challenge. The skin-reducing mastectomy (SRM) pattern has been widely described to manage skin redundancy; however, immediate single-stage prepectoral reconstruction can be burdened by high complication rates in this specific population. While two-stage reconstruction with tissue expanders represents a classic alternative, patient-reported outcomes after SRM using this approach have not been reported in the literature. Materials and methods: We retrospectively reviewed a consecutive cohort of patients with large and ptotic breasts who underwent SRM and two-stage submuscular tissue expander reconstruction between 2022 and 2024. The primary objective was to evaluate postoperative complication rates. Secondary objectives included a preliminary evaluation of patient-reported outcomes six months after definitive implant placement using the validated BREAST-Q Reconstruction Module, alongside a narrative benchmarking of our results against historical literature series. Tissue expanders were placed in a dual-plane submuscular-subdermal pocket without the use of acellular dermal matrices. Results: A total of 22 patients were included. Twenty patients (90.9%) successfully completed the two-stage reconstruction, while two (9.1%) experienced expander failure requiring explantation and autologous salvage, thereby excluding them from the BREAST-Q analysis. The total complication rate was 27.3% (6/22), and the surgical revision/implant failure rate was 9.1% (2/22). The BREAST-Q analysis highlighted high satisfaction scores regarding implants and postoperative breast appearance while revealing lower scores related to sexual well-being and cancer concerns. The literature review identified four relevant historical series characterized by small cohorts and the complete absence of patient-reported outcome data. Conclusions: The use of a two-stage submuscular tissue expander after SRM in patients with ptotic, large breasts represents a feasible and reliable alternative for managing skin redundancy with an acceptable complication profile in a high-risk population. Given the retrospective and uncontrolled nature of this preliminary study, further prospective comparative trials are required to establish definitive comparative effectiveness.