Abstract
BACKGROUND: The use of acellular dermal matrix (ADM) in prepectoral implant-based breast reconstruction has become increasingly widespread, aiming to enhance prosthetic support, reduce capsular contracture, and improve aesthetic outcomes. However, ADM remains a subject of debate due to its elevated cost and concerns regarding surgical morbidity. Current evidence is largely derived from retrospective, non-randomized studies, which limits the overall strength of available data. This study aims to clarify its clinical utility by conducting a meta-analysis of postoperative complications and a systematic review. METHODS: A systematic review was conducted according to PRISMA guidelines, including observational studies comparing outcomes of prepectoral reconstruction with and without ADM. Postoperative complications were analyzed using risk ratios (RRs) with 95% confidence intervals (CIs). A random-effects model was used for outcomes with substantial heterogeneity (I(2)>50%); otherwise, a fixed-effect model was applied. RESULTS: Nine studies involving 1,455 patients met inclusion criteria. No statistically significant differences were found in most complications: reoperation (RR: 1.02; 95% CI: 0.52-1.98; P=0.91), capsular contracture (RR: 0.72; 95% CI: 0.19-2.75; P=0.49), dehiscence (RR: 0.97; 95% CI: 0.40-2.35; P=0.93), hematoma (RR: 0.98; 95% CI: 0.29-3.28; P=0.96), implant removal (RR: 0.74; 95% CI: 0.46-1.20; P=0.16), infection (RR: 0.73; 95% CI: 0.51-1.05; P=0.07), necrosis (RR: 1.27; 95% CI: 0.64-2.53; P=0.41), rippling (RR: 0.54; 95% CI: 0.01-37.58; P=0.59), and seroma (RR: 0.81; 95% CI: 0.65-1.02; P=0.07). However, a subgroup analysis by reconstructive technique revealed notably higher rates of seroma (14.04% vs. 4.26%) and infection (12.62% vs. 0.74%) in tissue expander (TE)-based reconstruction compared to direct-to-implant (DTI) procedures. CONCLUSIONS: Prepectoral reconstruction with and without ADM shows similar complication rates. While ADM may offer structural and aesthetic benefits in selected patients, it also increases costs and may carry added risk. Because all included studies were retrospective and non-randomized, the level of evidence remains limited. These findings highlight the need for future prospective randomized trials to better define the role of ADM in clinical practice.