Reply: Does Staged Breast Reduction before Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques.

Abstract

Sir: We thank the authors for reading our study and appreciate their interest in our work.1 As nipple-sparing mastectomy continues to become more standardized, refining techniques will help expand indications and minimize complications in more challenging patient populations. In our study, breast reduction weights had a wide range, as breast size and morphology varied significantly. Reductions were individualized for each case to reduce volume, appropriately reshape the breast, and move the nipple-areola complex. Patients in this cohort were deemed candidates for staged reduction based on both size and ptosis, but do not represent a uniform morphology. The authors state that “too much excision can result in increasing the rate of ischemic complications”; however, this is not necessarily true. Large-volume breast reduction can be safely performed as is thoroughly reported in the literature using different reduction techniques.2–4 In such cases, proper planning and execution while appropriately taking into consideration the perfusion of the nipple-areola complex and the skin flaps and residual breast mound will minimize complications. Along these lines, preserving the superficial perfusion to the nipple-areola complex from the desired interspace perforators is paramount during both reduction and mastectomy. This holds true for both large- and small-volume staged reductions. It should be noted that the importance of staged reduction goes beyond simply excising breast tissue or changing size. The concept of “preshaping,” as discussed by Gunnarsson et al., is critical.5 Appropriately repositioning the nipple-areola complex and managing excess skin in a single stage in macromastic and ptotic patients is extremely difficult without committing to Wise-pattern mastectomy incisions, which may carry higher rates of necrosis.6 Vascular delay in nipple-sparing mastectomy is not a new concept.7–9 However, it is important to note that several concepts are at work in staged reduction beyond—and likely more important than—vascular delay. These include decreasing preoperative breast size (which has been shown to be a risk factor for ischemic complications),10 managing excess skin, repositioning the nipple-areola complex, and facilitating an easier mastectomy to minimize retraction damage to the skin envelope. In addition, the authors mention periareolar incisions, which are not used in our practice because of their increased risk of nipple necrosis.11–13 The single case of complete nipple necrosis in the staged group was described in the article. Given the small sample size in the staged cohort, this resulted in a 6.5 percent full nipple necrosis rate. The low number of patients in the staged group may have prevented certain differences between the two cohorts from being captured, as discussed in the article, but we could not draw any conclusions about full nipple necrosis from our data. However, we reported a significantly lower rate of major mastectomy flap necrosis. In addition, minor mastectomy flap and nipple necrosis trended lower, although again, further research in a larger cohort of patients is needed to draw conclusions about these outcomes. In the context of these complications, it is necessary to reiterate the importance of an anatomical mastectomy that preserves the second and third interspace perforators supplying the nipple-areola complex. Of the nine patients that underwent bilateral prophylactic nipple-sparing mastectomy in the staged cohort, seven had a high risk genetic mutations, one patient had a significant family history of breast cancer, and one patient had the presence of high-risk lesions. We continue to perform staged reduction before nipple-sparing mastectomy in the appropriate prophylactic cases and have also found the utility of this technique in certain therapeutic cases. Staged reduction before therapeutic mastectomy has been previously reported by Spear et al.7 and in more recent series on staged reductions before nipple-sparing mastectomy.14 In the appropriate patients, oncoplastic reduction is performed at the time of partial mastectomy. Patients then will undergo chemotherapy, as needed, after which a completion mastectomy is performed. We have found staged reduction to be a powerful technique in the appropriate cases. Although it is not a flawless solution for all patients with severe macromastia and ptosis, it has helped us expand indications for nipple-sparing mastectomy to patients who would not otherwise be candidates. We hope that future research in larger populations will help further refine indications and elucidate reconstructive and patient-reported outcomes with this technique. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.