Reply: Hybrid Prepectoral Breast Reconstruction: A Surgical Approach That Combines the Benefits of Autologous and Implant-Based Reconstruction.

Abstract

Sir: We thank Dr. Ad-El for his interest in our work and appreciate the opportunity to comment on his remarks regarding our recent publication on hybrid breast reconstruction.1 We certainly welcome his questions and comments and hope to be able to address his concerns. It appears as if the indication for hybrid breast reconstruction is questioned. In brief, we believe that hybrid breast reconstruction is a viable option for patients who desire autologous reconstruction and have abdominal skin laxity in the absence of soft-tissue volume. Thus, hybrid reconstruction permits coverage of an implant with well-vascularized abdominal soft tissue, thus minimizing the risk for postoperative implant rippling and simultaneously improving abdominal contour. The fact that we have the ability to use an implant as a structural foundation that provides volume and projection allows us to limit the abdominal flap harvest to correction of the existing skin laxity only, thus minimizing the risk of a high-riding abdominal scar and the appearance of a tight abdomen. As stated in our publication,1 the concept of combining autologous flaps with implants is not new, and we commend Dr. Ad-El for having experience with the traditional approach to hybrid reconstruction (i.e., latissimus dorsi flap combined with an implant). What we propose is an expansion of that concept that combines the ideal autologous donor site for breast reconstruction (i.e., the abdomen) with placement of an implant. We have disclosed what we believe to represent advantages of abdominal tissue versus latissimus flap for breast reconstruction in our Discussion.1 Dr. Ad-El’s comment regarding the complication rate is somewhat puzzling. The complication rate following our proposed approach falls within the range of what is published for autologous reconstruction, including the rate of mastectomy skin necrosis.2,3 In addition, the statement regarding an “augmented complication rate” of prepectoral versus subpectoral reconstruction has to be regarded as unsubstantiated based on contemporary literature. Large studies have demonstrated the safety associated with prepectoral breast reconstruction.4 It deserves mention that the rate of mastectomy skin necrosis is affected more by mastectomy technique than by plane of device insertion. Certainly, augmenting the reconstructed breast beyond its preoperative size in the immediate setting carries the risk of mastectomy skin flap compromise; however, the plane of implant insertion is hardly a contributing factor. The final issue commented on is related to cost. Specifically, Dr. Ad-El raises the issue that “it will be hard to justify the extra cost as a routine procedure for breast reconstruction.” It is important to highlight that we do not believe that hybrid breast reconstruction is a routine procedure but rather recommend it in a select group of patients. We previously discussed what we believe to represent patient characteristics that would justify a hybrid approach.5,6 As to cost, this question cannot definitely be answered based on contemporary data. However, as the proposed approach eliminates the need for a scheduled expander/implant exchange and minimizes the need for secondary fat grafting, the accumulated cost may not be higher after all. Performing hybrid reconstruction with a latissimus dorsi flap and subpectoral implant placement is certainly an acceptable approach. However, we believe that our proposed approach is associated with a decrease in patient morbidity. In fact, the very basis of our study is to minimize patient morbidity by transitioning the plane of implant insertion from subpectoral to prepectoral.1,6 We are puzzled by Dr. Ad-El’s conclusion that the hybrid approach should be limited to patients who have an absent pectoralis muscle and disagree with the notion that our approach combines the disadvantages of both reconstructive modalities. We believe that our experience has demonstrated the safety of this approach. Furthermore, we believe that in the context of modern breast reconstruction, microsurgical modalities should no longer be considered an overly complex endeavor but rather a routine approach that lends itself to technical modifications for the purpose of improving clinical outcomes. DISCLOSURE Dr. Momeni is a consultant for Allergan, AxoGen, Sientra, and Stryker. Dr. Kanchwala is a consultant for Allergan and AxoGen. Arash Momeni, M.D.Division of Plastic and Reconstructive SurgeryStanford University Medical CenterPalo Alto, Calif. Suhail Kanchwala, M.D.Division of Plastic SurgeryUniversity of Pennsylvania Health SystemsPhiladelphia, Pa.