Support or Simplicity: Evaluating Mesh Use in Two-Stage Prepectoral Breast Reconstruction

BACKGROUND: The routine use of surgical mesh in prepectoral two-stage breast reconstruction has increased despite limited high-level evidence supporting its necessity. The purpose of this study was to evaluate whether mesh use impacts postoperative complications, reconstructive failure, or secondary revision rates. METHODS: A multicenter retrospective cohort study was conducted of patients undergoing immediate prepectoral two-stage breast reconstruction from 2016 to 2025, stratified by use of mesh at the time of expander placement. Patients undergoing delayed reconstruction or concurrent/planned autologous reconstruction were excluded. Logistic regression models assessed predictors of (1) postoperative complication, (2) reconstructive failure, and (2) secondary revision. RESULTS: The final sample included 1,592 reconstructions in 948 patients, of which 84.4% used mesh. Complications occurred more frequently in reconstructions with mesh (18.2% vs. 12.9%, p=0.039), primarily due to higher infection rates (8.7% vs. 4.8%, p=0.039). On multivariable analysis, mesh use was associated with increased odds of complication (OR: 1.574, 95% CI: 1.047-2.437, p=0.035) but not reconstructive failure (OR: 1.222, 95% CI: 0.684-2.181, p=0.499). Secondary revision rates did not differ significantly between the two cohorts (21.5% vs. 24.4%, p=0.333) and mesh use was not found to be protective of secondary revision (OR: 1.165, 95% CI: 0.821-1.653, p=0.392). CONCLUSION: In prepectoral two-stage breast reconstruction, mesh use was associated with increased postoperative complications, particularly infection, and did not confer a reduction in reconstructive failure or secondary revision rates. While mesh is a useful adjunctive tool commonly used in breast reconstruction, its routine incorporation in two-stage reconstruction is costly and may not be necessary.