Unveiling Upper-Limb Dysfunction Early After Implant-Based Breast Reconstruction: Insights from a Retrospective Cohort Study

Background: Prepectoral (PP) breast reconstruction has emerged as a muscle-sparing alternative to the subpectoral (SP) approach. While aesthetic and oncologic outcomes have been well studied, early functional recovery remains less explored. Methods: This retrospective study assessed upper-limb function in women who underwent implant-based breast reconstruction, comparing direct-to-implant PP and two-stage SP approaches. Outcomes at one month included Quick Disabilities of Arm, Shoulder e Hand (QuickDASH) questionnaire, shoulder range of motion (ROM), International Physical Activity Questionnaire (IPAQ), and Body Image Scale. An exploratory analysis within the PP cohort compared outcomes according to implant coverage materials: acellular dermal matrix (ADM), synthetic mesh, and polyurethane-coated (PU). Results: Among 124 patients, 63 underwent PP and 61 SP reconstruction. PP patients reported lower disability (QuickDASH), better body image, and a lower prevalence of pathological shoulder ROM, particularly in internal rotation and flexion. Functional complications, including adherent scars, dysesthesia, lymphosclerosis, implant hypomobility, and pain, were less frequent in the PP group. Furthermore, fewer PP patients required postoperative rehabilitation. In multivariable analysis, only previous upper-limb dysfunction remained independently associated with higher QuickDASH scores. Within the PP group, ADM-and mesh-based reconstructions were associated with more favorable outcomes than PU implants and remained associated with lower disability after adjustment. Conclusion: Early postoperative upper-limb function following implant-based reconstruction is influenced by both reconstructive approach and patient-related factors, e.g., preexisting upper-limb dysfunction. Muscle-sparing strategies may support a more favorable functional outcome in the short term, though this hypothesis must be interpreted cautiously given the retrospective design of our study. Level of evidence iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .