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Reply: How to Preshape the Breast for a Successful Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction in the Challenging Breast.

the axilla as needed. The intended preshaping procedure may differ from the standard reduction because of minimal glandular touch, whereas more glandular resection and reshaping usually take place when subsequent mastectomy is not planned. The implant gives the final shape to the reconstructed breast as the skin drapes over the implant. This is why the resected weight during the preshaping procedure was deemed irrelevant to the results. We would like to see the nipple spared more often in therapeutic mastectomies, and loss of the nipple in prophylactic cases is difficult to accept. This study proves the benefits of preshaping on nipple-areola complex vascularity and vascular safety of subsequent nipple-sparing mastectomy in a selected group of patients. Further studies are warranted in light of these facts and findings to test the limits of its safety. DOI: 10.1097/PRS.0000000000004227 Reply: How to Preshape the Breast for a Successful Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction in the Challenging Breast Sir: We thank Dr. Li and Dr. Luan for their interest in our article, “Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?”1 With regard of their question of how the preshaping procedure is done, it is not imperative, in terms of nipple-areola complex survival, because it does not rely on axial blood supply. It will, in contrast, affect the end result of the reconstructed breast. A little over 5 years ago, we performed nipple-sparing mastectomy and direct-to-implant breast reconstruction on patients who have had previous breast reductions, not knowing whether the nipple would survive. Plan B was to remove the nipple-areola complex if necrosis occurred. Fortunately, the blood supply was consistently adequate and plan B was not once needed. We went on to test this theory to be true and conclude that the preshaping procedure of choice should be one that the surgeon is comfortable with and that fits the goal of the procedure. With an implant, you are not creating a breast; you are creating the illusion of a breast. The nipple-sparing mastectomy skin flap camouflages the implant to resemble the missing breast, and the preshaping procedure makes the transition from the challenging breast toward the more ideal shape and location a better fit for direct-to-implant reconstruction. We emphasize three key elements of the preshaping procedure: (1) base definition, (2) envelope adjustment, and (3) nipple-areola complex relocation. The base is imperative for the implant location on the chest wall and needs to be narrowed down and relocated according to the planned base of the implant (Fig. 1). The envelope should be reduced to the desired breast size, taking into account the geometry of an implant. Larger breasts consist of expanded skin and various proportions of fat and glandular tissue that must be reduced and preconditioned to withstand the challenges of the subsequent nipple-sparing mastectomy. The nipple-areola complex is often overly stretched and must be reduced in size and relocated to be on top of the desired breast mound in a symmetric fashion (Fig. 2). The preshaping procedure follows the preglandular mastectomy plane that is fairly well established in these patients. Glandular resection is mostly performed laterally and outside the boundaries of the footprint. The new footprint on the chest wall is left intact to minimize scar tissue in the prepectoral area and facilitate subsequent mastectomy. The wide exposure provided by the Wise pattern offers complete control over glandular tissue removal as far up along Fig. 1. The footprint of the breast in terms of the ptotic contralateral breast.