Letter to the Editor: Sub-muscular Reconstruction After NAC Sparing Mastectomy—Direct to Implant Breast Reconstruction with Human ADM Versus Tissue Expander

Abstract

We read with interest the study of Sgarzani et al. [1] comparing unilateral direct to implant (DTI) sub-muscular breast reconstruction with human acellular dermal matrix (ADM) to two-stage breast reconstruction with sub-muscular tissue expander and subsequent replacement with silicone implant. The authors must be commended for attempting to analyze objectively the esthetic outcome of two different breast reconstruction techniques by comparing self-evaluated satisfaction by the Breast Q questionnaire, observer-evaluated symmetry by 11 breast surgeons blinded to each other and symmetry of anthropometric measures and volume. Fifty-four patients were included in the study all having NAC sparing mastectomy without a history of radiotherapy: 28 patients with DTI reconstruction and 26 patients with two-stage reconstruction. Though comparing outcome of 2 different breast reconstruction methods is much needed, it is always a challenge as recognized by the authors. To limit the impact of incision type on final esthetic outcome, their retrospective, observational, non-randomized study was wisely restricted to patients undergoing NAC sparing mastectomy with only an S-shaped incision located on the supero-external breast quadrant, their preferred skin incision because, as they claim, it allows NAC vascularity preservation while allowing visualization of the mastectomy anatomical plane without excessive traction on skin flaps. The authors, however, did not provide information about the age of their patients at the time of reconstruction, body mass index (BMI), smoking status, preoperative diagnosis and stage of the disease, adjuvant chemotherapy, nor about the type and manufacturer of silicone implants inserted (round or anatomical, textured or smooth). Also, neither the resected specimen’s volume nor the volume of implants used were specified. Though it is implied that NAC sparing mastectomy is indicated for small and medium breasts as mentioned in their discussion, the authors did not provide information about preoperative breast measurements, inframammary fold position, presence of preoperative ptosis or symmetry status. A disturbing element in this study, however, is the fact that half the patients with two stages, and none with DTI reconstruction had contralateral symmetrization indicating a clear bias in assigning initially patients for the single or two-stage reconstructions. Evidence provided from comparison of 2 non-randomized groups has a limited power and cannot be highly considered. In addition, while the two techniques were compared for symmetry, and in particular with respect to the position of the infra-mammary fold (IMF), the authors did not specify how they have corrected IMF asymmetry whenever it was diagnosed preoperatively. Regarding evaluation of outcome symmetry on bi-dimensional photographic documentation, the authors have mentioned that the 11 independent observers (all breast surgeons) were blinded to each other, but it is not clear whether they were blinded as well to the type of & Fadl Chahine [email protected]