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• W3136314225 abstract "Sir: We read the article entitled “Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients” by Safran et al. with great interest.1 Breast cancer is a very common problem in women, affecting not only their body image but also their feminine sexuality. Breast reconstruction is an essential step in the pathway toward full psychosocial and physical recovery, and implant-based procedures still represent the first reconstructive option offered to women following mastectomy. For this reason, we suggest the use of BREAST-Q to evaluate quality of life before and after surgery, grounded not only on physician’s considerations but also on objective studies. The BREAST-Q is actually the most used questionnaire in the world for evaluation of patient-reported outcomes.2 For sure, the best way to return a patient to a normal life is to provide an immediate solution. This can be accomplished by the choice of a direct-to-implant breast reconstruction, which means faster recovery times and lower costs compared to a standard two-stage procedure. Our first consideration regards the possibility of using a single-stage approach in the majority of patients: this is not always the best choice for them, depending on a variety of factors, such as the anatomy of the breast, the type and severity of tumor, and not least the skills and the techniques of the surgical oncologist performing the mastectomy. A two-stage reconstruction offers the chance, when the tissue expander is replaced with the permanent implant, to perform a pocket revision and a contralateral breast symmetrization for a better result. The second consideration regards implant placement: in our experience, only a minority of reconstructions can be handled with a single-stage prepectoral approach as, in most cases, the thickness of the skin flaps is not suitable for a prepectoral implant. In this article, there is no mention about the thickness of the mastectomy flaps. The authors used a clinical approach to define whether there is a well-perfused mastectomy flap or not, without using a standardized approach to determine the minimal thickness (expressed in millimeters) requested to perform a prepectoral reconstruction, to avoid or limit the risk of implant extrusion.3 We think that submuscular dissection is not so arduous and time consuming, if compared with the time spent for “pocket controlling technique,” the use of the sizers, and the potential use of acellular dermal matrix. Moreover, although in retropectoral reconstruction the postoperative pain and the need for narcotics are higher, seroma formation and postoperative hematoma are more common in prepectoral reconstruction.3 Furthermore, patients who undergo direct-to-implant reconstruction usually experience significantly higher implant replacement rates than those undergoing reconstruction in two stages.4 Besides, in this clinical series, the mastectomies were performed by nine surgical oncologists in two different hospitals: this obviously leads to an extreme variability of the skin flaps thickness, which could be considered a “bias” for the study. The lack of patient-related exclusion criteria could lead to an incorrect indication for this type of procedure. Some studies demonstrated that proper patient selection is critical for success in prepectoral reconstruction.5 Some patients may achieve excellent outcomes following prepectoral implant placement; others will be better served by either dual-plane or total submuscular placement. This decision should be made according to patient characteristics and intraoperative markers of mastectomy flap viability. It would also be appropriate to specify the length of follow-up to better determine the rate of long-term complications. DISCLOSURE None of the authors has a financial interest in any of the products or devices mentioned in this communication. Silvia Ciarrocchi, M.D.Mauro Barone M.D., Ph.S.Marco Morelli Coppola, M.D.Barbara Cagli, M.D., Ph.D.Annalisa Cogliandro, M.D., Ph.D.Paolo Persichetti, M.D., Ph.D.Department of Plastic, Reconstructive, and Aesthetic SurgeryCampus Bio-Medico UniversityRome, Italy" @default.
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• W3136314225 date "2021-03-24" @default.
• W3136314225 modified "2023-09-23" @default.
• W3136314225 title "Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients" @default.
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• W3136314225 doi "https://doi.org/10.1097/prs.0000000000007709" @default.
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