Compliance with Specific Recommendations and Tasks Reduces Nipple Necrosis Rates in Prepectoral Implant-Based Reconstruc
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LETTER – BREAST ONCOLOGY
Compliance with Specific Recommendations and Tasks Reduces Nipple Necrosis Rates in Prepectoral Implant-Based Reconstruction After Nipple-Sparing Mastectomy Gianluca Franceschini
, and Riccardo Masetti
Multidisciplinary Breast Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Universita` Cattolica del Sacro Cuore, Rome, Italy
Nipple-sparing mastectomy (NSM) with prepectoral implant-based reconstruction (PIBR) is an oncologically accepted technique that allows to improve aesthetic outcomes and patient quality of life.1,2 We agree with Sterling E. Braun and colleagues that the plane of implant placement should not affect the risk of nipple-areola complex (NAC) ischemia;1 the success of PIBR is linked to the perfusion of skin flaps after NSM that mainly depends on patient-related risk factors and surgeon’s expertise.3 As regards patient-related risk factors, a multidisciplinary discussion, in a dedicated ‘‘Surgery Meeting’’ with a careful patient assessment and disease staging, is essential to select the best candidates to NSM and PIBR; NSM should never be performed in inflammatory carcinoma and locally advanced tumor infiltrating the skin and/or NAC;2 patients with specific medical comorbidities compromising perfusion of mastectomy flaps, high BMI [ 30 kg/m2, large breasts, active smoking, previous radiotherapy, and NAC surgery should not be considered for PIBR due to increased risk of NAC necrosis.3–5 A preoperative evaluation by a three-stage breast tissue coverage classification via digital mammography might be helpful to predict the viability of the remaining flaps after NSM and select the optimal reconstructive plane.6
Regarding surgical experience, NSM with PIBR involves a series of more demanding procedures that need appropriate learning, surgical practice, and dexterity. A skillful technique is crucial to minimize the risk of NAC necrosis; however, surgical dexterity is useful but not sufficient to optimize the outcomes. A successful NSM with PIBR requires both individual ability and technical capacity but also dedication, decision-making skills, and the repetitive performance of standardized tasks, such as:7,8 •
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• Society of Surgical Oncology 2020 First Received: 10 August 2020 Accepted: 18 August 2020; Published Online: 1 September 2020 G. Franceschini e-mail: [email protected]
Appropriate choice of skin incision tailored to patient to better preserve vascular integrity of NAC: lateral-radial incision or axillary or inframammary crease incision are preferable. Meticulous dissection of mammary gland in subdermal fascial plane preserving an adequate subcutaneous thickness in order to maintain vascular viability; the manoeuvre of blunt dissection using the fingertips may help to find the correct surgical plane. Careful separation of the gland by all borders avoiding medial perforators that provide a significant vascular supply to skin flaps. Accurate excision of retroareolar tissue
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