Direct‐to‐Implant Versus Two‐Stage Tissue Expander/Implant Reconstruction: A Decade of Institutional Experience From China

ABSTRACT Background The choice between direct‐to‐implant (DTI) and two‐stage tissue expander/implant (TE/I) breast reconstruction remains debated. This study aimed to compare complication profiles between these techniques and evaluate the modifying effect of postoperative radiotherapy in a large Asian cohort. Methods A retrospective single‐center analysis was performed on patients who underwent immediate prosthetic breast reconstruction from 2014 to 2023. Patients were grouped by DTI or TE/I. Propensity score full matching was used to balance baseline covariates. Subgroup analysis by postoperative radiotherapy status was conducted. Results 569 female patients (600 breasts) were included. 437 patients (465 breasts) underwent DTI and 132 patients (135 breasts) underwent TE/I breast reconstruction. After full matching on the propensity score, the TE group had significantly higher risks of any complication ( p = 0.002), reconstructive failure ( p < 0.001), implant or expander removal ( p < 0.001), and exposure of implant or expander ( p < 0.001) compared with the DTI group. In the subgroup analysis, TE/I had higher risks of failure, removal, and exposure in the non‐radiotherapy subgroup, whereas in the radiotherapy subgroup most complications showed no intergroup differences, and TE/I had a significantly lower risk of flap necrosis ( p = 0.002). Conclusions TE group had higher complication rates than DTI group, but postoperative radiotherapy significantly modifies the risk profile. In irradiated patients, TE may offer a protective effect against flap necrosis. These findings provide evidence‐based guidance for individualized surgical decision‐making in Asian populations.