Invited Response on: Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis

Abstract

We read with great interest the commentary on our latest article about the challenging topic of immediate breast reconstruction following nipple-sparing mastectomy (NSM) on patients with large, ptotic breasts [1]. We thank the authors for their interest in our study and are grateful for the opportunity to explain some of the fine details regarding our technique. With the advancements in the knowledge of breast cancer treatment, conservative approaches are becoming the preferred methods in selected patients. NSM can be considered as a hallmark from the reconstructive perspective, as it allows the results to be more natural and less devastating on the psychosocial well-being of the patients. Unlike skin-sparing mastectomy (SSM), preservation of the nipple–areolar complex (NAC) itself for its physical properties such as projection, color and texture provides an unmatched result after the reconstruction [2]. However, a conservative approach can be challenging for patients with large, ptotic breasts, as the remaining skin envelope has the potential to undergo mastectomy flap necrosis, if not reduced. On the other hand, excessive reduction can also disrupt vascularity of the mastectomy skin flaps and make certain areas, especially the NAC, vulnerable to necrosis. To address this challenging patient group, several approaches have been described. Type IV SSM, as referred to in the commentary, is a technique with the definition of ‘‘nipple-areola removed with an inverted or reduction pattern skin incision’’ [3]. Although the reduction pattern can be somewhat similar to our method, this technique involves removal of the NAC and was not the technique used in our study. Skin-reducing mastectomy (SRM) is another approach for single-staged reconstruction in patients with large, ptotic breasts [4]. This method classically involves implant coverage by a dermal flap at the lower pole, where the dermal flap is combined with the pectoralis muscle. In addition, the NAC is usually removed and free grafted in this method [5] (although variations that preserve the NAC have been described [6]). Therefore, this was not the method used in our study either, as a de-epithelized dermal flap was not used in our completely musculofascial pocket. In short, our approach was purposefully named as ‘‘NSM with or without skin reduction,’’ to use an accurate description. Similar simultaneous and staged approaches in this context were discussed and compared with our technique within our manuscript. Preparation of the musculofascial pocket in our study is well described in our current and previous studies [7–9], as well as in the literature by other experienced centers [10–13]. However, we believe that the dissection and elevation of the fascial continuity of the pectoralis major muscle at the inferior pole requires surgical expertise, patience, anatomical knowledge, and is associated with a learning curve. We disagree with the authors’ statement of ‘‘only a small permanent implant may be inserted in such a pocket.’’ With the correct surgical technique, the & Sukru Yazar [email protected]