Negative Pressure–Guided Selective ADM Grafting for Upper Medial Contour Refinement in Prepectoral Direct-to-Implant Breast Reconstruction

Background: In prepectoral implant-based breast reconstruction, contour depression of the upper medial pole remains a common aesthetic limitation. This study evaluated whether negative pressure–assisted intraoperative assessment combined with selective acellular dermal matrix (ADM) grafting improves aesthetic outcomes. Methods: We retrospectively reviewed patients who underwent unilateral prepectoral direct-to-implant reconstruction. Patients were categorized into three groups according to the method of additional ADM graft to the upper medial pole: no additional ADM (Group 1), clinically guided ADM placement (Group 2), and negative pressure–assisted ADM placement (Group 3). Aesthetic outcomes were evaluated using the modified Garbay and Harvard scales by blinded observers. Monotonic trends across ordered groups were analyzed using the Jonckheere–Terpstra test. Results: A total of 81 patients were included. The modified Garbay scores did not differ significantly among groups. Breast shape demonstrated a progressive improvement from Group 1 to Group 3, although this did not reach statistical significance. On the Harvard scale, overall aesthetic scores showed a significant increasing trend from Group 1 through Group 3 (p = 0.023). When analysis was limited to the upper medial pole, a clear stepwise improvement was observed across Groups 1, 2, and 3 (p = 0.003). Conclusion: Negative pressure–assisted intraoperative assessment with selective ADM grafting of the upper medial pole was associated with improved contour-specific aesthetic outcomes in prepectoral implant-based breast reconstruction.