Sir: We thank Dr. Parisi and colleagues for their interesting response to our article.1 Conceptually, we completely agree that it is always better to have as much coverage of the implant as possible. In our practice, this is muscle, a deepithelialized dermal flap, or even potentially an acellular dermal matrix or mesh. This will provide potentially less rippling in the long term, as there is thicker coverage of the implant. However, it may not necessarily decrease the complication rates as far as sepsis and seroma are concerned, especially if an acellular dermal matrix or mesh is used. Coverage of the implant by whatever manner also does not necessarily change the perfusion of the mastectomy flaps, although tension in the repair may. Well established is the practice that unless an acellular dermal matrix or mesh is used, the surgeon is limited to using a skin-reducing mastectomy pattern with inferior deepithelialized dermocutaneous flap to cover the lower pole of the implant. If total muscular coverage is desired, a combination of the pectoralis major and the serratus anterior muscle is used. This will obviously limit the size of the prosthesis that can be placed in this relatively small pocket, as described in Dr. Parisi et al.’s letter. From a postoperative cosmetic point of view, in the lazy-S approach, the upper two-thirds of the implant is covered by the mastectomy flap and the pectoralis major muscle; thus, it is uncommon to have postoperative rippling in this area. If the lower mastectomy flap is very thin (<1 cm) then, not uncommonly, there will be some rippling in this area. This is usually corrected at the time of nipple-areola complex reconstruction with lipofilling of the lower mastectomy flap. It is also vital that the inframammary fold is retained during the mastectomy and that a tight snug pocket is reconstructed around the implant; otherwise, there is a high chance that the patient may end up with implant malposition or implant rotation. Mastectomy flap necrosis is one of the major concerns of which any breast reconstructive surgeon is acutely aware. The mastectomy needs to be performed in the mastectomy plane, and this can be vague; however, with appropriate traction on the skin and countertraction on the breast organ itself, the avascular white line can be seen and the mastectomy needs to be performed in this plane. If the mastectomy is performed in the correct plane, all that remains is the subcutaneous fat and the overlying skin. Although the patient’s body habitus often dictates the flap thickness, this is not always the case. The premise that the more weight the patient is carrying, generally the thicker the flap, cannot solely predict mastectomy flap. The blood supply to the mastectomy flaps after mastectomy is provided by the subdermal plexus, and if it is removed or damaged at the time of mastectomy, the surgeon should expect to have mastectomy flap necrosis. We do not routinely evaluate the mastectomy flap thickness before surgery and therefore there is no absolute number to use for the thickness of the mastectomy flap, as it varies from patient to patient. The most accurate way to determine perfusion and viability of the mastectomy flaps is to use intraoperative laser angiography [such as the SPY system (LifeCell Corp., Branchburg, N.J.)],2 which we do not use. If this is not available, débridement of the edges of the mastectomy flap will indicate the perfusion of that specific flap, and if there is doubt about the perfusion, the flaps can be trimmed back until the surgeon is happy with the perfusion. If there is not enough remaining skin to cover a large enough implant, the patient can then be converted to an expander prosthesis reconstructive pathway. Some patients are prone to wound healing problems, such as those with a high body mass index, diabetic patients, poorly controlled human immunodeficiency virus–positive patients, previously irradiated patients, and smokers. These women may have a higher postoperative complication rate in relation to wound healing and minor flap necrosis and should be approached and counseled with care. The reconstructive surgeon should have a much lower threshold to use an expander prosthesis reconstructive pathway for these high-risk patients. ACKNOWLEDGMENT The study received ethics approval from the Human Research Ethics Committee of the University of the Witwatersrand (M111121). DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. L. Charles J. Serrurier, F.C.S.Plast.Surg.(C.M.S.A.)Sarah Rayne, B.Sc.(U.C.L.), M.R.C.S.(Eng.), F.C.S.(S.A.)Marisse Venter, F.C.S.Plast.Surg.(C.M.S.A.)Carol-Ann Benn, F.C.S.(S.A.)University of the Witwatersrand and Milpark Breast Care Centre of ExcellenceJohannesburg, South Africa
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Dec 1, 2023
Naohiro Ishii 
Open Access
