Enhancing methodological rigor in prepectoral breast reconstruction studies

Correspondence to: Janhavi Venkataraman (email: Janhavi.Venkakataraman@hcahealthcare.co.uk; janhavivraman@gmail.com)

The London Breast Institute

Princess Grace Hospital

42-52 Nottingham Place

London

W1U 5NY

UK

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BJS, https://doi.org/10.1093/bjs/znaf032, published 25 February 2025

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The article by Harvey et al. on patient-reported outcomes (PROs) following prepectoral implant-based breast reconstruction in the UK (Pre-BRA study)1 is valuable, but several methodological considerations must be addressed to improve interpretation and applicability.

A primary concern is the heterogeneity of surgical techniques. Variability in the use of biological mesh and single- versus two-stage reconstruction affects generalizability. Notably, patients without biological mesh face higher risks of complications such as rippling, while acellular dermal matrix (ADM) can mitigate this issue, enhancing aesthetics and satisfaction. In our prospective study of 72 patients with ADM-assisted prepectoral reconstruction, we observed a low complication rate (2.8%) and no cases of significant rippling requiring fat grafting or implant loss after 18.3 months2.

Surgeon expertise and technique further influence PROs. The multicenter nature of the study introduces variability, limiting direct applicability to specific institutions. Vidya et al.3 proposed a grading system for rippling severity (1–4), highlighting the benefits of cohesive gel implants and ADM in patients with thin skin flaps. Implementing this system and incorporating lipomodelling for grades 2–4 could improve outcomes.

Moreover, the study lacks adjustments for confounders like radiation and comorbidities, which can affect PROs. Multivariable analysis or propensity score matching could improve validity. Long-term follow-up is crucial to assess complications like late rippling or capsular contracture.

Future studies should standardize surgical approaches, particularly regarding biological mesh in single-stage reconstructions, to ensure reproducibility, and include subgroup analyses, where possible. The inclusion of a control group (e.g., subpectoral reconstruction or no reconstruction) could improve conclusions about the prepectoral technique’s benefits.