LAUSR

To the Editor, We read with interest the results of the iBAG study, a Braxon post‐market surveillance study, published by J. Masià et al. Masià reports on 1450 operated breast, but gives no information on the percentage of single‐stage direct‐to‐implant reconstruction or two‐stage breast reconstruction, which is important for the complication rate. As our results were discussed in this paper by Masià, we want to clarify, that we did 200 nipple‐sparing mastectomies with single‐ stage direct‐to‐implant breast reconstructions. Masià reported on 1450 operated breasts, but only 49.7%, 720 breasts were nipple‐ sparing mastectomies. Masià mentioned our complication rates to be quite higher than those reported in the iBAG study. He compared his necrosis rate of 3.2%, which is calculated for 1450 breasts and not for 720 breasts with nipple‐sparing mastectomy, what would calculate for 6.4%, with our nipple necrosis rate of 7%, which was superficial only without any loss of NAC. This led him to the wrong consideration, the surgical approach was the critical factor for outcome measurements. There are several studies confirming the inframammary fold incision as a safe and cosmetically perfect incisional access. The visibility of the retroareolar region and the exact excision of the breast gland and the ducts is feasible in experienced hands after a certain learning curve. Main reasons for NAC‐necrosis are surgical reasons, as incisions around the NAC or too close tot he NAC. In general, the main reasons for complications after nipple‐sparing mastectomy are surgical reasons and not the usage of one or another kind of matrix. The seroma rate in our study was 14.5% and was assessed after removal of the drain, which was removed when less than 20ml secretion was produced within 24 h. The quantity of necessary punctures was described in our paper. The seroma rate in the iBAG study was 7.7%, which is much lower, but without any further information on the seroma assessment and puncture quantity. Seroma development after surgery in a pocket with allogene material is a logical consequence of the surgery. The repeated discussions on seroma formation without information on the length of stay of the drain, the secretion within 24 h before removal, and mostly important the necessity and quantity of seroma evacuation do not add any knowledge. The most important factor implant loss was 3.5% in our study and 6.5% in Masià's paper, but if extrusion of implant (1.2%) is added, it counts even for 7.7%. Alltogether it is very difficult to find the true complication rate in Masià's publication. The immediate complication rate is reported 13.8% (200 breasts), and the late complication rate with 4.2% (61 breasts), in the text, but this is not apparent in table 2 of his paper. The total complication rate in our publication is 14.5%. In general, we are the proponents and advocates for prepectoral implant based breast reconstruction after nipple‐sparing mastectomy and promote the further implementation of this method—but iBAG a milestone?