Discussion: Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy in Large and Ptotic Breasts

Dear Sir, We read with great interest the paper entitled ‘‘Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy (WPSRM) in Large and Ptotic Breasts’’ by Inbal et al. [1]. We agree with the authors about the minor psychological impact in the one-stage breast reconstruction, and we also agree that the wise pattern remains in use for mastectomies of large and ptotic breasts with acceptable outcomes because it has wide applicability to the greater grades of breast hypertrophy and breast ptosis [1]. The authors perform a retrospective study of consecutive patients who underwent WPSRM and immediate implantbased breast reconstruction at their institution and propose an algorithm for improving patient and implant selection. By reading the sample data we noticed that no patients were smokers. We believe this was a decisive factor in reducing the risk. In fact, in clinical practice, we try to avoid immediate reconstructions in smokers even though it is a relative contraindication [2]. We would like to ask if smoking is an absolute or relative contraindication in their practice. We also believe that it can be a factor to be considered in a therapeutic algorithm for immediate breast reconstruction. Skin necrosis is a frequent complication in this type of surgery and may result in the loss of the breast implant. To prevent the exposure of the implant we use negative pressure therapy in the immediate postoperative period [3]. In fact, it is known that negative pressure increases tissue perfusion with improved microcirculation [4]. This has allowed us to avoid further surgical times and also to save the areola–nipple complex in nipple-sparing-mastectomy. We believe it can be useful in managing necrotic complications of the skin in immediate breast reconstruction with implants. We believe it is very interesting and we are grateful for the precise risk assessment for every 100 g of weight of mastectomy. Although it is not always possible to estimate the preoperative amount of tissue to be removed, in our opinion it is a very useful intuition.