As survival continues to improve for patients with breast cancer, postoperative quality of life (QoL) has become an increasingly important factor in surgical decision-making. Breast reconstruction is an integral component of comprehensive breast cancer care, and the choice of reconstructive technique has a profound impact on long-term functional recovery and psychosocial well-being.Presented at the 2026 ASCO Annual Meeting, the Phase III PREPEC trial represents the highest level of evidence to date comparing prepectoral and subpectoral implant-based breast reconstruction in a prospective randomized setting. The study demonstrated that prepectoral reconstruction significantly improved physical well-being of the chest, psychosocial well-being, sexual well-being, and breast satisfaction, although these benefits came at the expense of a higher risk of implant loss or replacement.
In this edition of ASCO China Perspective, Oncology Frontier invited Professor Benlong Yang from Fudan University Shanghai Cancer Center to interpret this landmark study from a Chinese clinical perspective. Drawing on the anatomical characteristics of Chinese women and current domestic practice, Professor Yang discusses the benefits and risks of the two reconstructive approaches, evaluates the future role of prepectoral reconstruction in China, and shares practical strategies for optimizing patient selection and surgical outcomes.
Expert Commentary
Q1. Oncology Frontier: The Phase III PREPEC trial evaluated the impact of prepectoral versus subpectoral implant-based breast reconstruction on patients’ quality of life. What are your thoughts on the study findings?
Professor Benlong Yang:
The PREPEC trial is a pragmatic, multicenter, large-scale Phase III randomized controlled trial involving 383 patients across 26 centers in 10 countries. It represents the highest level of prospective evidence comparing prepectoral and subpectoral immediate implant-based breast reconstruction, with a rigorous study design and substantial clinical relevance.
I would summarize the findings from three key perspectives.
1. Clear improvement in patient-reported quality of life
Using the BREAST-Q questionnaire—the gold standard for patient-reported outcomes—the investigators assessed quality of life over a 24-month follow-up.
Patients undergoing prepectoral reconstruction achieved a physical well-being of the chest score of 79.2, compared with 74.3 in the subpectoral group, representing a statistically significant mean difference of 4.8 points (P=0.01), exceeding the predefined minimal clinically important difference.
In addition, secondary quality-of-life outcomes—including sexual well-being, psychological well-being, and breast satisfaction—all consistently favored the prepectoral approach. The benefits were observed across multiple subgroups, including unilateral versus bilateral surgery, one-stage versus two-stage reconstruction, different mastectomy techniques, and patients receiving radiotherapy.
These high-quality data confirm that prepectoral reconstruction substantially reduces long-term chest discomfort while avoiding many classic complications associated with subpectoral reconstruction, such as:
- Pectoralis muscle contracture
- Limited shoulder mobility
- Chronic chest wall pain
- Animation deformity
These findings are consistent with the current trend toward surgical de-escalation and less invasive breast surgery.
2. The increased risk of implant failure is real
The study also demonstrated that unplanned implant removal or replacement occurred more frequently after prepectoral reconstruction (21.1% vs 14.5%), representing an adjusted absolute difference of 5.7%.
Consequently, the trial failed to demonstrate the anticipated non-inferiority for implant-related safety, challenging earlier conclusions from smaller single-center studies suggesting comparable safety between the two approaches.
Early complications—including seroma, skin flap necrosis, infection, and implant exposure—were modestly more common in the prepectoral group. Conversely, capsular contracture, implant malposition, and animation deformity occurred less frequently.
Therefore, the complication profile differs between the two techniques rather than representing an overall increase in complications.
3. Important limitations
PREPEC was designed as a pragmatic real-world trial. Surgical meshes, implant types, and staged reconstruction techniques were not standardized, reflecting routine clinical practice.
However, the study population consisted predominantly of Western women. Differences in body habitus, chest wall soft-tissue thickness, radiotherapy utilization, and baseline disease characteristics limit the direct applicability of these findings to Chinese patients.
Accordingly, PREPEC should serve as valuable evidence to inform clinical decision-making rather than support universal adoption of prepectoral reconstruction.
Q2. Oncology Frontier: Considering that Chinese women generally have thinner chest wall soft tissues and that breast-conserving surgery and reconstruction are rapidly increasing in China, how do you think PREPEC will influence reconstructive practice domestically? Could prepectoral reconstruction become the mainstream approach?
Professor Benlong Yang:
The implications of PREPEC for China should be considered from two perspectives.
Risk-stratified patient selection will become the dominant strategy
Historically, subpectoral reconstruction has been the predominant implant-based technique in China because of concerns regarding limited soft-tissue coverage and implant exposure with prepectoral reconstruction.
Following PREPEC, I believe we will increasingly adopt a risk-stratified approach, selecting:
- Prepectoral reconstruction for carefully selected low-risk patients
- Subpectoral reconstruction for patients at higher risk
Patients who are unlikely to require postoperative radiotherapy, possess adequate chest wall soft tissue, or undergo elective prophylactic mastectomy are ideal candidates for prepectoral reconstruction because they experience less postoperative pain, faster functional recovery, and no muscle contracture.
Conversely, patients with anticipated radiotherapy, thin soft tissues, or previous chest wall surgery should continue to receive subpectoral reconstruction.
Patient expectations are also driving change
Breast cancer patients in China are becoming younger, and increasing numbers prioritize postoperative quality of life and upper-limb function.
Many patients are willing to accept a carefully managed increase in surgical risk in exchange for superior long-term comfort and cosmetic outcomes, which will further expand appropriate indications for prepectoral reconstruction.
Nevertheless, prepectoral reconstruction is unlikely to become the dominant national standard in the near future
Several important barriers remain.
1. Anatomical considerations
Chinese women generally have thinner subcutaneous tissue and thinner prepectoral soft-tissue coverage than Western women. This represents perhaps the greatest obstacle to widespread adoption, as applying PREPEC findings directly may increase risks of flap necrosis and implant exposure.
2. Higher rates of radiotherapy
Compared with Western trial populations, Chinese patients more frequently receive neoadjuvant therapy and postoperative radiotherapy, both of which compromise flap vascularity and increase the likelihood of implant-related complications after prepectoral reconstruction.
3. Economic considerations
Prepectoral reconstruction commonly requires biologic or synthetic mesh to support the implant. These materials remain expensive in China, and reimbursement is limited, restricting broad implementation.
Over the next five to eight years, I anticipate a dual-track model:
- Subpectoral reconstruction will remain the preferred approach for intermediate- and high-risk patients.
- Prepectoral reconstruction will steadily expand among carefully selected younger, low-risk patients but is unlikely to completely replace subpectoral reconstruction nationwide.
Q3. Oncology Frontier: Based on PREPEC and current Chinese practice, how can surgeons optimize patient selection and surgical technique to maximize quality-of-life benefits while minimizing implant failure?
Professor Benlong Yang:
The first priority is careful patient selection, which represents the most important step in risk management.
Patients best suited for prepectoral reconstruction include:
- Skin flap thickness ≥5 mm
- No previous chest wall radiotherapy
- No anticipated postoperative radiotherapy
- Prophylactic mastectomy (such as BRCA mutation carriers)
- Ductal carcinoma in situ (DCIS)
- No skin fibrosis following neoadjuvant chemotherapy
- Unilateral surgery
- No previous chest wall trauma or reconstructive procedures
Patients who should preferentially undergo subpectoral reconstruction include:
- Severe skin edema or fibrosis after neoadjuvant therapy
- Chest wall soft tissue <3 mm
- High likelihood of postoperative radiotherapy
- Large primary tumors or extensive axillary nodal involvement
- Obesity with diabetes
- Chronic corticosteroid therapy
- Peripheral vascular disease
For patients expected to receive postoperative radiotherapy after neoadjuvant treatment, delayed-immediate reconstruction may be preferable, allowing definitive prepectoral reconstruction after completion of radiotherapy and soft-tissue recovery.
Optimizing surgical technique and implant selection
Reducing implant failure requires attention to several technical details.
Individualized use of biologic or synthetic mesh
Because Chinese patients generally have thinner soft tissues, complete implant wrapping with synthetic mesh or acellular dermal matrix (ADM) is often preferable to partial coverage, helping distribute tension and reduce implant exposure.
Patients at high risk for radiotherapy may benefit from more durable biologic meshes, whereas lower-risk patients without planned radiotherapy may be suitable candidates for more cost-effective synthetic alternatives.
Implant selection tailored to Chinese anatomy
Lower-profile, moderate-projection silicone implants are generally preferable because they reduce excessive tension on the skin flap.
Given the relatively smaller breast base width among Chinese women, implant dimensions should closely match chest wall anatomy.
For high-risk patients, a two-stage tissue expander approach may be safer than immediate permanent implant placement, allowing gradual expansion before definitive reconstruction.
Refining surgical technique
Several operative details are particularly important:
- Preserve the subcutaneous fascial layer and subdermal vascular plexus during mastectomy to maintain flap perfusion.
- Employ dual closed-suction drainage with delayed drain removal to reduce seroma formation.
- Apply layered postoperative compression dressings to minimize dead space, thereby reducing seroma formation and subsequent capsular contracture.
Optimizing perioperative management
Given the relatively high use of postoperative radiotherapy in China, careful perioperative planning is essential.
Whenever possible, postoperative radiotherapy should be initiated three to four months after surgery, once complete flap healing has occurred.
Patients undergoing radiotherapy require close surveillance for compromised flap vascularity, and early intervention for skin breakdown is essential to prevent progression to implant exposure requiring explantation.
Study Summary
Background
The optimal implant plane for implant-based breast reconstruction following therapeutic or prophylactic mastectomy remains controversial.
Traditional subpectoral reconstruction provides robust soft-tissue coverage but requires elevation of the pectoralis major muscle, potentially resulting in postoperative pain, restricted shoulder movement, and animation deformity.
Prepectoral reconstruction, by avoiding muscle dissection, is technically simpler and less invasive but provides less soft-tissue coverage, raising concerns regarding implant-related complications.
The international Phase III PREPEC trial was therefore designed to determine whether prepectoral reconstruction could improve long-term patient-reported quality of life compared with the conventional subpectoral approach.
Methods
This superiority trial enrolled women aged ≥18 years undergoing skin-sparing (SSM) or nipple-sparing mastectomy (NSM) for breast cancer treatment or risk reduction.
Participants were randomized 1:1 to receive either prepectoral or subpectoral implant-based breast reconstruction, while all other aspects of surgery followed standard institutional practice.
The primary endpoint was BREAST-Q physical well-being of the chest at 24 months, with a predefined minimal clinically important difference of 4 points.
The principal safety endpoint was implant or tissue expander loss or replacement within 24 months.
Results
Between July 2020 and February 2023, 383 patients were enrolled across 26 centers in 10 countries, with 380 patients included in the final analysis.
At 24 months, prepectoral reconstruction produced significantly better physical well-being of the chest, with least-squares mean scores of 79.2 versus 74.3, corresponding to a 4.8-point improvement (P=0.01).
Prepectoral reconstruction also showed favorable trends in:
- Psychosocial well-being
- Sexual well-being
- Satisfaction with breasts
Regarding safety, implant or expander loss/replacement occurred in 21.1% of patients undergoing prepectoral reconstruction compared with 14.5% following subpectoral reconstruction.
Overall complication rates were similar (54.1% vs 55.9%), although early complications were more common after prepectoral reconstruction, whereas late complications occurred more frequently after subpectoral reconstruction.
Conclusion
The PREPEC trial demonstrates that prepectoral implant-based breast reconstruction provides clinically meaningful improvements in long-term quality of life compared with subpectoral reconstruction. However, these benefits are accompanied by a higher risk of implant or expander loss or replacement, highlighting the importance of individualized patient selection and careful balancing of quality-of-life gains against implant-related risks.
Professor Benlong Yang
Fudan University Shanghai Cancer Center
