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Choosing among prepectoral direct-to-implant (DTI), submuscular DTI, and two-stage expander reconstruction remains complex. This study analyses outcomes from a large single-centre cohort to define a pragmatic, evidence-based decision-making algorithm.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective monocentric review included all consecutive IBBR procedures performed between 2018 and 2024. Patients were allocated to three groups: prepectoral DTI (n\u00a0=\u00a0601), submuscular DTI (n\u00a0=\u00a0142), and two-stage expander reconstruction (n\u00a0=\u00a044). Demographic, oncologic, and surgical variables were collected. Major complications were evaluated using unadjusted analyses and inverse-probability-of-treatment weighting. A dedicated subgroup analysis was performed for patients receiving postmastectomy radiotherapy (PMRT).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 1,093 breasts were reconstructed. Weighted analysis showed similar overall major-complication rates for prepectoral and submuscular DTI (7.3% vs 8.4%,\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0=\u00a00.278), while expanders demonstrated the lowest adjusted risk (0.7%). Within the PMRT subgroup, prepectoral DTI did not show increased infection, dehiscence, or seroma compared with the other techniques; infection was significantly lower than in submuscular DTI (2.7% vs 14.3%,\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0=\u00a00.020). Capsular contracture was markedly less frequent in prepectoral DTI and remained significantly reduced after multivariable adjustment (OR 1 [reference]; OR 9.03 for submuscular DTI; OR 3.25 for expanders).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our resulting algorithm offers a structured, patient-specific approach to optimise outcomes in immediate implant-based breast reconstruction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence IV<\/jats:title>\n                    <jats:p>\n                      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\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/www.springer.com\/00266\" ext-link-type=\"uri\">www.springer.com\/00266<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00266-026-05900-5","type":"journal-article","created":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T17:19:15Z","timestamp":1778606355000},"page":"5043-5055","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Immediate Implant-Based Breast Reconstruction: Analysis of 787 Cases and Definition of Our Decision-Making Algorithm"],"prefix":"10.1007","volume":"50","author":[{"given":"Federico","family":"Taraschi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liliana","family":"Barone Adesi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicole","family":"Ratti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Visconti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Ricci","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Scardina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianluca","family":"Franceschini","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marzia","family":"Salgarello","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,12]]},"reference":[{"key":"5900_CR1","unstructured":"World Cancer Research Fund. 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