Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life

We have read with great interest the paper entitled ‘‘Direct-to-implant subcutaneous breast reconstruction: A systematic review of complications and patient’s quality of life’’ by Silva J. et al. [1]. The authors performed a systematic review on the safety and quality of life assessment after subcutaneous direct-toimplant reconstruction and a meta-analysis comparing subcutaneous vs subpectoral direct-to implant reconstruction complications. The authors propose a well-performed review of the literature bringing up interesting insight on how the technological advances have brought back the subcutaneous reconstruction as a valid and comparable workhorse to autologous and submuscular immediate reconstruction [2]. The subcutaneous approach was discarded for years for the increased risk of mastectomy skin flap necrosis, capsular contracture, implants exposure and removal, especially after radiotherapy [3]. The success of direct-to-implant strictly depends on patient’s selection [4] in terms of breast size, smoking habits, diabetes, vascular conditions, obesity which have always been considered detrimental in the choice of the reconstructive approach [5]. In this review, patients at risk for complications due to their comorbidities and risk factors were included. A comparison of complications rate among those patients versus ideal patients would have allowed to identify their impact on procedure outcome [6, 7]. I found extremely interesting the analysis on the BREST-Q results and the overall patient satisfaction in favor of the subcutaneous approach, but we have some elements to discuss [8]. In the meta-analysis comparing submuscular to subcutaneous direct-to-implant, no statistically significant difference was demonstrated in the odds of well-known complications such as skin-flap and NAC necrosis, capsular contracture and implant removal. No difference was noted among the two groups in terms of type of mastectomy, need for chemotherapy or radiation therapy, risk-factors when complication rates were analyzed. During mastectomy the skin flap survival [9, 10] is primarily dependent on the vessels lying in the subdermal layer of the mastectomy flaps hence superficial to the dissection plane [8]. The incision type and its impact on superficial vascularization in combination with patient characteristics affect the rate of skin necrosis and overall complications [11, 12]. No analysis was done comparing mastectomy surgical access and only few assessed in a scientific manner the viability of the skin flap for decision making. The meta-analysis is less instrumental when comparing the rate of capsular contracture. The value of the study could be improved by increasing the mean follow-up and by performing a sub-analysis in terms of use of ADM, mesh or polyurethane implants, [