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Reply: Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

Lim, Geok Hoon F.R.C.S.; Baildam, Andrew D. F.R.C.S.

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 140e
doi: 10.1097/PRS.0000000000005729

Breast Department, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Republic of Singapore, Breast Unit, St. Bartholomew’s Hospital, London, United Kingdom

Breast Unit, St Bartholomew’s Hospital, The Breast Clinic, King Edward VII’s Hospital, London, United Kingdom

Correspondence to Dr. Lim, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899, Republic of Singapore,

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We thank Drs. Li and Luan very much for their interest in our article, “Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy.”1 To answer their queries, first, the specification of implants in our series was based on various factors. The implants were selected by measuring the breast base width and height, subtracting an element for skin and subcutaneous tissue, and choosing the desired breast projection. This tissue-based planning approach was also the superior method used for the selection of implants for breast augmentation.2 The volume of the implant used was chosen based on the patient’s current breast volume, ptosis, and desired final reconstructed breast size, as mentioned in our article.

The goal was not to match the volume of tissue excised during mastectomy but to ensure symmetry of both breasts after risk-reducing mastectomy. As risk-reducing mastectomy was often carried out bilaterally, implants of the same size were chosen.

Although capsular contracture could be attributed to infection and hematoma, it was not witnessed in our limited series with a median follow-up of 18 months. We also did not experience any surgical complications of infection or hematoma, as we adhered to strict hemostasis and infection control protocols, such as perioperative antibiotic administration, minimal operating room traffic, minimal operating time, and so forth.3 Particularly for our technique, as the implant had a dual-plane placement with pectoralis muscles (superiorly) and capsule-only coverage inferiorly, we would recommend careful dissection, especially in the lower pole of the implant when performing the mastectomy, to avoid breach of the capsule, which was not witnessed in our series.

Finally, with regard to skin flap necrosis, this was again not witnessed in our series or in a somewhat similar series of patients who underwent submuscular implant augmentation and oncologic mastectomy years later.4 This may be related to the mastectomy being a staged procedure, which could allow interim recovery of the deep vascular system. More importantly, optimization of patients’ risk factors, such as controlling diabetes and proper tissue handling, could reduce the incidence of skin flap necrosis. The results from our pilot study have been promising, and longer-term studies to recruit more patients will be conducted. We hope this clarifies their queries and thank them once again for their interest in our novel risk-reducing mastectomy technique.

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The authors declare no conflict of interest and have no financial disclosures to report.

Geok Hoon Lim, F.R.C.S.Breast DepartmentKK Women’s and Children’s HospitalDuke-NUS Medical SchoolRepublic of SingaporeBreast UnitSt. Bartholomew’s HospitalLondon, United Kingdom

Andrew D. Baildam, F.R.C.S.Breast UnitSt Bartholomew’s HospitalThe Breast ClinicKing Edward VII’s HospitalLondon, United Kingdom

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1. Lim GH, Baildam AD. Novel approach for risk-reducing mastectomy: First-stage implant placement and subsequent second-stage mastectomy. Plast Reconstr Surg. 2018;142:607–610.
2. Adams WP Jr, Mckee D. Matching the implant to the breast: A systematic review of implant size selection systems for breast augmentation. Plast Reconstr Surg. 2016;138:987–994.
3. Barr SP, Topps AR, Barnes NL, et al.; Northwest Breast Surgical Research Collaborative. Infection prevention in breast implant surgery: A review of the surgical evidence, guidelines and a checklist. Eur J Surg Oncol. 2016;42:591–603.
4. Salgarello M, Rochira D, Barone-Adesi L, Farallo E. Immediate breast reconstruction after skin- or nipple-sparing mastectomy for previously augmented patients: A personal technique. Aesthetic Plast Surg. 2012;36:313–322.
Copyright © 2019 by the American Society of Plastic Surgeons