Comparative analysis of breast cancer-related lymphedema after autologous and implant-based reconstruction: emphasizing differences between prepectoral and subpectoral placement of implant.

BACKGROUND

This study aimed to compare the incidence and long-term progression of breast cancer-related lymphedema (BCRL) following autologous or implant-based breast reconstruction, with subgroup analysis based on prepectoral versus subpectoral implant placement.

METHODS

A retrospective review was conducted of 228 patients who underwent mastectomy and immediate breast reconstruction by a single surgeon between 2017 and 2020, using either a deep inferior epigastric perforator (DIEP) flap or a tissue expander. Arm circumference was measured at standardized proximal and distal points. BCRL was diagnosed clinically and confirmed by lymphoscintigraphy demonstrating dermal backflow and/or delayed axillary nodal uptake. Soft-tissue compliance was assessed using ultrasonography to evaluate differences in tissue response with and without compression.

RESULTS

The overall incidence of BCRL showed no significant difference among groups (DIEP 8.9%, prepectoral 14.8%, subpectoral 15.6%). However, during 2-year follow-up, the subpectoral group demonstrated faster progression and greater limb volume increase compared with the DIEP and prepectoral groups. Improvements in soft-tissue compliance were greatest in the DIEP group, followed by the prepectoral group, while the subpectoral group showed the least improvement.

CONCLUSIONS

Autologous reconstruction demonstrated the most favorable lymphatic outcomes, supporting prior literature. Among implant-based approaches, prepectoral placement was associated with a milder course of BCRL than subpectoral placement, possibly due to decreased postoperative pain and shoulder restriction. These findings suggest that reconstruction type and implant placement plane may influence BCRL severity and should be considered when planning surgery to reduce complications and optimize long-term outcomes.