Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience

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I read with great interest the article by De Vita et al.1 concerning nipple-sparing mastectomy with implant-based reconstruction. The authors should be commended for their efforts on, to the best of our knowledge, one of the largest clinical series of nipple-sparing mastectomy implant-based reconstructions. Understanding the risk factors for complications would help to improve the informed consent process and assist plastic surgeons and patients alike with treatment decision. Thus, this is a thoughtful article that should be relevant to many plastic and breast surgeons.
Recently, there has been a resurgence of interest in nipple-sparing mastectomy outcomes, and this study again illustrates the value of this evaluation. As the authors point out, several clinical series have been performed to evaluate factors that impact the development of nipple-sparing mastectomy complications. A critical survey of the literature shows that nipple-sparing mastectomy is normally performed by numerous techniques.2,3 Habitually, the technique differs from surgeon to surgeon and is dependent on the type of reconstruction and the breast volume. In the present study, the authors observed that, in the majority of cases, surgical access is related to the lateral pole lazy-S and the inframammary fold. However, patients requiring Wise pattern incision were excluded, and there is no mention about the direct-to-implant approach, or the use of tissue expander/implant-expanders. Do the authors have these data or is there no indication for these approaches in their experience? It has been our experience that the Wise pattern involves breasts that require a conspicuous reduction of the skin envelope and offers a wide exposure with control of the skin envelope.4 However, the Wise pattern approach has some limitations because the lateral/medial skin flaps that close down to the inframammary fold may become ischemic, and implant exposure can be observed. Thus, for this group of patients, the implant-expander concept can be advantageous. The implant-expander is usually placed on a partial submuscular pocket, depending on the condition of the flaps. During the postoperative period, the implant is totally deflated to avoid skin tension/congestion. After recovery, adjustments in volume are made, with less risk of flap complications.3,5
Another important point is related to the surgeon factors that are known to be associated with complications. Technical variability among breast surgeons may play a role in outcome. Thus, it would be helpful to include in the regression model factors known to be associated with complications, such as experience. There could be an interaction between the surgeon and one of these complications that would provide better insight into this association.
The present study has some limitations that should be recognized. First, this large sample is retrospective and not randomized. This aspect is attributable to inclusion and exclusion criteria and the patient selection for each technique. Second, the authors analyzed the risk factors that potentially influenced the short-term surgical outcome rather than the long-term complications. As such, they did not analyze capsule contracture, dislocation, rotation, pain, late seroma, revision rates, or long-term patient dissatisfaction. Third, the satisfactory results are attributable to a close collaboration with the breast surgery team in terms of incision selection and skin flap dissection. We recognized that this aspect is not frequently observed in current clinical practice. It has been our opinion that the good results are attainable only if these techniques are indicated and the teamwork concept is followed very closely.
In conclusion, the authors have performed a thoughtful study with a retrospective design. The authors described important risk factors that are relevant to the informed treatment decision-making process. It is well understood that randomized controlled trials are the gold standard for producing high-level evidence.
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