Enhancing Prepectoral Direct-to-Implant Reconstruction Using the Serratus Anterior Fascia: The Hybrid Plane

Summary: Immediate breast reconstruction has advanced significantly, yet optimal implant placement remains debated. Prepectoral implant-based breast reconstruction (IBR) offers aesthetic benefits but risks implant exposure and ptosis. Although acellular dermal matrices mitigate these risks, they pose complications such as infection, red breast syndrome, and high costs. Here, we aim to describe and evaluate our technique using the serratus anterior fascia as an autologous alternative for lower pole and lateral support in prepectoral IBR. All patients undergoing prophylactic or curative nipple-sparing mastectomy with immediate prepectoral direct-to-implant reconstruction between October 2023 and December 2024 received the hybrid plane technique and were included. In total, 10 patients received this technique (19 breasts). The mean age was 40.9 years, and the mean body mass index was 22.6 kg/m². All patients had pathogenic mutations, most commonly BRCA1. Three (30%) patients experienced complications, but no reconstruction failures occurred. Mean follow-up was 12.8 months. The absence of implant exposure despite postoperative complications, including wound dehiscence, highlights the safety and protection from the serratus anterior fascia. Similar to its use in subpectoral reconstruction, the serratus anterior fascia can improve prepectoral IBR, offering a safe and cost-free solution for total skin- and nipple-sparing mastectomies.