Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies.

Abstract

Sir: It was with great pleasure that we read the interesting article by Frey et al.1 entitled “Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies,” and we congratulate the authors on their thoughtful study. Nowadays, nipple-sparing mastectomy has allowed good aesthetic results without oncologic detriment to the patient and with minimal complications.2 The authors compared in their study outcomes between one- and two-stage implant-based and autologous tissue-based breast reconstruction in terms of complications after nipple-sparing mastectomy, without analyzing the aesthetic outcomes. We would like to emphasize some aspects of the study and further discuss them. The authors reported an overall 8.8 percent rate of mastectomy flap necrosis in the tissue expander group, 19.4 percent in the immediate implant group, and 14.4 percent in the autologous tissue group. These percentages seem to be fairly high and might be reduced using specific devices to better evaluate skin mastectomy flap quality and viability, such as near-infrared laser-assisted indocyanine green imaging.3 Also, skin mastectomy flap thickness plays an important role in determining skin flap necrosis, and we would like to know the percentage of mastectomy skin flap necrosis following therapeutic and prophylactic mastectomy for each group. We do not completely understand why the autologous tissue–based reconstruction group has a significantly higher rate of major mastectomy flap necrosis where well-vascularized tissue is placed underneath mastectomy flaps, which can improve their vitality. Furthermore, only 27 percent of autologous tissue–based breast reconstruction patients underwent therapeutic mastectomy. Finally, we would like to know whether major cellulitis and mastectomy flap necrosis occurred in prophylactic or tumor patients, in whom skin flap thickness may be an important risk factor. In conclusion, the authors are to be commended for their study, and we hope to read another article comparing the aesthetic results and patient satisfaction in these three groups of patients undergoing nipple-sparing mastectomy and reconstruction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Stefano Bonomi, M.D.Laura Sala, M.D.Umberto Cortinovis, M.D.Department of Plastic Reconstructive SurgeryFondazione IRCCS Istituto Nazionale dei TumoriMilano, Italy