Abstract
BACKGROUND: Direct-to-implant (DTI) breast reconstruction has become a widely accepted approach for postmastectomy breast reconstruction. Traditionally, implants were placed in the subpectoral (SP) plane to maximize soft tissue coverage; however, recent advances in surgical technique and implant materials, such as acellular dermal matrices (ADMs) and meshes, have led to a resurgence in the prepectoral (PP) approach. Recent studies have shown conflicting evidence regarding their respective complication profiles and patient-reported outcomes. Thus, comprehensive head-to-head meta-analysis is needed to evaluate the safety and effectiveness of PP versus SP in DTI breast reconstruction. METHODS: Following PRISMA guidelines, this systematic review and meta-analysis will compare complication rates and patient-reported outcomes between PP and SP in DTI reconstruction. MEDLINE (PubMed), Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.org will be searched to identify comparative studies. Eligible studies must report at least one primary outcome, such as capsular contracture or surgical complications. Secondary outcomes will include BREAST-Q scores, pain scores, and length of hospital stay. Data will be extracted independently by two reviewers, and methodological quality will be assessed using appropriate risk of bias tools (ROBINS-I for nonrandomized studies and Rob 2 for randomized controlled trials). Meta-analysis will be performed using Review Manager 5.4, applying random-effects models in cases of significant heterogeneity. Subgroup and sensitivity analyses will be conducted where applicable. DISCUSSION: This study aims to synthesize the current evidence comparing PP and SP in DTI breast reconstruction to inform surgical decision-making and optimize patient outcomes. The results will provide surgeons and patients with a clearer understanding of the benefits and risks associated with each reconstructive plane.