What Is Prepectoral Breast Reconstruction?
Prepectoral breast reconstruction is an implant-based technique in which the breast implant is placed above the pectoralis major muscle — in the subcutaneous plane, on top of the muscle — rather than beneath it. Because the muscle no longer covers the implant, a biological matrix is used to support the device, define the pocket, and reinforce the soft-tissue envelope. The approach is also described as "above-the-muscle" or "muscle-sparing" reconstruction.
For decades, implant-based reconstruction was performed submuscularly (or in a dual-plane), lifting the pectoralis major to cover the upper pole of the implant. Prepectoral reconstruction reverses that logic: the muscle is left undisturbed in its natural position, and a biological matrix takes over the supportive role. The technique became practical at scale once dependable soft-tissue support materials — biological matrices and acellular dermal matrix (ADM) — made reliable above-the-muscle coverage possible.[5]
Prepectoral vs. Subpectoral Reconstruction
The central difference between the two approaches is the plane of the implant relative to the pectoralis major muscle. That single choice cascades into differences in muscle handling, recovery, and the type of soft-tissue support required.
| Attribute | Prepectoral (above muscle) | Subpectoral / Dual-plane (below muscle) |
|---|---|---|
| Implant plane | On top of the pectoralis major, in the subcutaneous pocket | Partially or fully beneath the pectoralis major |
| Muscle handling | Muscle left intact and undisturbed (muscle-sparing) | Muscle elevated and divided to create the pocket |
| Animation deformity | Avoided — implant does not move with muscle contraction | Possible — visible distortion when the muscle contracts |
| Postoperative pain | Generally reduced, as the muscle is not manipulated | Muscle dissection can increase early discomfort |
| Soft-tissue support | Relies on a biological matrix / ADM for coverage and pocket control | Muscle provides part of the coverage |
| Key requirement | Adequate mastectomy-flap thickness and vascularity | More forgiving of thin flaps in some cases |
"Prepectoral, matrix-supported reconstruction repositions the implant above the muscle, avoiding the animation deformity and postoperative pain associated with submuscular techniques — a shift enabled by reliable soft-tissue support materials."
Prepectoral reconstruction principle · Vidya & Masià et al., 2017Who Is a Candidate for Prepectoral Reconstruction?
Prepectoral reconstruction is not universally suitable; candidacy depends on the quality of the mastectomy flaps and the overall oncologic and clinical picture. Surgeons typically consider the approach when the soft-tissue envelope can reliably support and perfuse an above-the-muscle implant.
- Mastectomy-flap quality: Adequate flap thickness and vascularity are important, since the flap and matrix — not the muscle — provide coverage.
- Nipple-sparing or skin-sparing mastectomy: Prepectoral techniques are frequently used in immediate reconstruction following these mastectomies.
- Desire to avoid animation deformity: Patients and surgeons prioritising a natural result during muscle activity often favour the prepectoral plane.
- Adjunctive refinement planned: Thin-flap patients may be managed with matrix support plus fat grafting to improve coverage and contour.
Patient selection, indications, and contraindications are clinical decisions made by the operating surgeon in the context of each patient. This page is educational and not a substitute for individualised medical advice.
The Role of Biological Matrix in Prepectoral Reconstruction
In the prepectoral plane, the biological matrix performs the supportive job the pectoralis muscle does in submuscular techniques. It reinforces the soft-tissue envelope, defines and stabilises the implant pocket, supports the lower pole and inframammary fold, and — being acellular — integrates and revascularises with the patient's own tissue over time.[1]
Matrices used in this setting include decellularised bovine pericardium and acellular dermal matrix (ADM). Bovine pericardium is valued for its dense, strong collagen structure and handling. For a complete explanation of what these scaffolds are and how they differ, see the pillar guide on the biological matrix for breast reconstruction and the detailed biological matrix vs. ADM comparison.
The Role of Fat Grafting in Prepectoral Reconstruction
Because the implant sits directly beneath the skin in prepectoral reconstruction, the thickness and quality of the overlying soft tissue strongly influence the aesthetic result — particularly the risk of visible rippling or implant palpability in thin-flap patients. Autologous fat grafting is widely used as an adjunct to add a layer of the patient's own tissue over the device, softening contours and improving coverage.
The durability of a fat graft depends heavily on how the harvested fat is processed before reinjection. Closed-system processing methods such as fat dialysis aim to wash and concentrate the graft while preserving the stromal vascular fraction (SVF), which supports graft take.[7] This is where ABC's EXAFAT system fits within the prepectoral workflow.
The Prepectoral Direct-to-Implant (DTI) Technique
In a direct-to-implant (DTI) prepectoral workflow, the reconstruction is completed in a single stage at the time of mastectomy, without a tissue expander. The biological matrix supplies the coverage and pocket control that the muscle would otherwise provide.
Following skin- or nipple-sparing mastectomy, the surgeon assesses mastectomy-flap thickness and perfusion to confirm suitability for above-the-muscle placement.
A biological matrix is prepared and used to construct or wrap the implant pocket on top of the pectoralis muscle, defining the borders and lower-pole support.
The definitive implant is positioned within the matrix-supported prepectoral pocket, with the muscle left intact beneath it.
The soft-tissue envelope is closed over the reconstruction. Adjunctive fat grafting may be planned — immediately or at a later stage — to refine contour and coverage in thin-flap patients.
Clinical Evidence for Prepectoral Reconstruction
The evidence base for prepectoral, matrix-supported reconstruction has grown substantially over the past decade. Foundational series by Vidya, Masià, Berna and colleagues (2017) established the technique and its rationale.[5] A multicentric prepectoral direct-to-implant series using an acellular bovine-pericardium matrix (De Vita 2024, n=65) reported a 9.2% major-complication rate (6/65),[1] and real-world registry data from the iBAG multicentre study (Masià 2020) captured 1,450 prepectoral procedures across 30 centres, giving large-scale outcome context.[3]
For comparative context on soft-tissue support materials, a meta-analysis of ADM in implant-based reconstruction (Zhu & Liu 2023, n=2,667) reported complication ranges commonly between 15% and 30%,[2] a randomised comparison of ADM versus synthetic mesh (Gschwantler-Kaulich 2016) found an overall major-complication rate around 31% similar across arms,[6] and a dedicated safety series on bovine pericardium in prepectoral reconstruction (Casella STEP 2025) adds device-specific data.[4]
The ABC Platform for Prepectoral Reconstruction
Advanced Biomedical Concept supports the full prepectoral workflow: the ExaShape and PREPEC bovine-pericardium biological matrices provide soft-tissue support and pocket control above the muscle, while the EXAFAT closed-system fat grafting device delivers the adjunctive autologous refinement that thin-flap prepectoral patients often need.
ExaShape and PREPEC sit within ABC's wider reconstructive platform, which also includes the BioShield Pocket® family, Grid, Expander, and NAC devices, alongside the EXAFAT® fat grafting system. See the full product range, or read the pillar guides on the biological matrix for breast reconstruction and fat dialysis for breast fat grafting.
Frequently Asked Questions
Common Questions
What is prepectoral breast reconstruction?
What is the difference between prepectoral and subpectoral reconstruction?
What are the advantages of prepectoral breast reconstruction?
Do you need a biological matrix for prepectoral reconstruction?
How does fat grafting fit into prepectoral reconstruction?
What does Advanced Biomedical Concept offer for prepectoral reconstruction?
References
- De Vita R, et al. "Prepectoral direct-to-implant breast reconstruction with acellular bovine pericardium matrix." Clin Breast Cancer. 2024. DOI: 10.1016/j.clbc.2024.06.004. (Prepectoral DTI series, n=65 — 9.2% major complications)
- Zhu L, Liu P. "Acellular dermal matrix in implant-based breast reconstruction: a meta-analysis." Aesthetic Plast Surg. 2023. DOI: 10.1007/s00266-023-03296-0. (ADM meta-analysis, n=2,667)
- Masià J, et al. "The iBAG multicentre study of prepectoral ADM reconstruction." J Surg Oncol. 2020. DOI: 10.1002/jso.26073. (Real-world registry, 1,450 procedures / 30 centres)
- Casella D, et al. "STEP: bovine pericardium in prepectoral reconstruction." J Clin Med. 2025. DOI: 10.3390/jcm14176296. (Device-specific safety series)
- Vidya R, Masià J, Berna G, et al. "Prepectoral implant-based reconstruction — foundational series." Breast J. 2017. DOI: 10.1111/tbj.12810. (Foundational prepectoral technique)
- Gschwantler-Kaulich D, et al. "ADM vs synthetic mesh: a randomised comparison." Eur J Surg Oncol. 2016. DOI: 10.1016/j.ejso.2016.02.007. (Randomised ADM vs mesh, ~31% both arms)
- Coleman SR, Saboeiro AP. "Fat grafting to the breast revisited: safety and efficacy." Plast Reconstr Surg. 2007;119(3):775–785. DOI: 10.1097/01.prs.0000252001.59152.8a. (Foundational fat grafting technique)