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The aim of this study was to compare the functional and economical outcomes of the prepectoral breast reconstruction (PPBR) versus the subectoral one. PPBR entailed significantly lower postoperative pain and faster upper limb functional recovery than subpectoral procedure. Moreover, PPBR largely reduced the need for symmetrization. Therefore, PPBR was also economically advantageous over traditional implant reconstruction.The breast reconstructive subpectoral technique commonly leads to functional consequences. Recently, a new conservative prepectoral breast reconstruction (PPBR) technique was proposed and its surgical safety and aesthetic effectiveness proved. The aim of this prospective nonrandomized study was to compare the functional and economical outcomes of the PPBR procedure versus the subpectoral one.From February 2015 to September 2016, 86 patients underwent mastectomy with immediate implant-based reconstruction. Thirty-nine patients were assigned to group 1 and received prepectoral acellular dermal matrix–wrapped implant reconstruction. The remaining 45 patients were assigned to group 2 and received a subpectoral implant or tissue expander. We recorded the operating time, length of hospital stay, analgesic consumption, postoperative pain, upper limb function, esthetic satisfaction, and quality of life. Additional surgical procedures for reconstruction completion or contralateral operation for symmetrization were also recorded.Compared to group 2 patients, group 1 patients showed less postoperative pain and faster upper limb functional recovery. Patients in group 1 also recorded a lower analgesic consumption and an earlier return to usual work. Moreover, the muscle-sparing technique improved aesthetic outcomes and largely reduced the need for symmetrization.Immediate breast reconstruction by using prepectoral muscle-sparing acellular dermal matrix–wrapped implant resulted in lower pain intensity and significant upper limb functional advantages compared to submuscular implant placement. Furthermore, when considering a series of ascertained benefits, PPBR is also economically advantageous, although future studies should better define its cost-effectiveness.