- Email: [email protected]
Results from the BRIOS randomised trial
Correspondence
Results from the BRIOS randomised trial In a multicentre randomised controlled trial1 in The Lancet Oncology, Rieky Dikmans and colleagues compare immediate two-stage breast reconstruction with one-stage (direct-to-implant) reconstruction and acellular dermal matrix (ADM) breast reconstruction after skinsparing mastectomy and nipplesparing mastectomy. We applaud the first randomised controlled trial to compare these two techniques. The authors report that grade 3 adverse events occurred in 26 (29%) of 91 operated breasts in the one-stage group, leading to implant, ADM, or both ADM and implant removal in 24 (26%) of the 91 breasts.1 At Guy’s Hospital Breast Unit, London, UK, between January, 2013, and December, 2016, we performed skin-sparing mastectomies and nipple-sparing mastectomies with single stage direct-to-implant and ADM reconstruction in 184 patients (288 breasts). Implant loss occurred in ten of 288 breasts (3∙4% loss rate). These data have been prospectively collected and publication is imminent. The 2012 UK oncoplastic breast reconstruction guidelines for best practice2 set the target of implant loss at less than 5%. Darragh and colleagues3 report an overall frequency of implant loss of 1∙9% in 105 breasts with immediate implant-based reconstructions. Sinha and colleagues4 compared 1491 two-stage procedures and 171 one-stage procedures and found a non-significant difference in the overall frequency of major infection (6∙4% one-stage group, 3∙4% two-stage group). Wilkins and colleagues5 compared different breast reconstructions, including implant, expander, and autologous techniques, and reported that failure occurred in 5∙9% of the 1615 implant-based procedures. Dikmans and colleagues1 admit that the surgeons who performed www.thelancet.com/oncology Vol 18 April 2017
ADM-based reconstructions had little experience in this technique. The authors hypothesise that impaired ADM neovascularisation might have affected the survival of the skin flaps. We strongly disagree, and propose that post-surgical viability of the skin flaps is dependent on the adequacy of the subdermal plexus over the preserved native skin envelope. In our experience, skin flap trauma, wound edge ischaemia, or infection-induced hypoxia are the main factors that affect blood supply to the mastectomy flap. We believe that the mastectomy technique and the experience of the surgeon are paramount to the success of this delicate procedure. Although this is the first randomised controlled trial1 to compare one-stage with two-stage implant recon struction, the frequency of implant loss in the study is high and should be interpreted with caution. We feel that direct-to-implant and ADM reconstruction by experienced surgeons in high-volume centres has an established role in immediate breast reconstructions and results in more natural aesthetic outcomes than twostage submuscular reconstructions.
5
Wilkins EG, Hamill JB, Kim HM, et al. Complications in postmastectomy breast reconstruction: one-year outcomes of the mastectomy reconstruction outcomes consortium (MROC) study. Ann Surg 2016; published online Nov 30. DOI:10.1097/ SLA.0000000000002033.
We declare no competing interests.
Tibor Kovacs, *Petros Charalampoudis, Bertha A in ’t Hout, Dorin Dumitru, Ashutosh Kothari [email protected] Breast Unit, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK 1
2
3
4
Dikmans REG, Negenborn VL, Bouman MB, et al. Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial. Lancet Oncol 2017; 18: 251–58. Cutress R, Summerhayes C, Rainsbury R. Guidelines for oncoplastic breast reconstruction. Ann R Coll Surg Engl 2013; 95: 161–62. Darragh L, Robb A, Hardie CM, McDonald S, Valand P, O’Donogue JM. Reducing implant loss rates in immediate breast reconstructions. Breast 2017; 31: 208–13. Sinha I, Pusic AL, Wilkins EG, et al. Late surgical-site infection in immediate implant-based breast reconstruction. Plast Reconstr Surg 2017; 139: 20–28.
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Results from the BRIOS randomised trial In a multicentre randomised controlled trial1 in The Lancet Oncology, Rieky Dikmans and colleagues compare immediate two-stage breast reconstruction with one-stage (direct-to-implant) reconstruction and acellular dermal matrix (ADM) breast reconstruction after skinsparing mastectomy and nipplesparing mastectomy. We applaud the first randomised controlled trial to compare these two techniques. The authors report that grade 3 adverse events occurred in 26 (29%) of 91 operated breasts in the one-stage group, leading to implant, ADM, or both ADM and implant removal in 24 (26%) of the 91 breasts.1 At Guy’s Hospital Breast Unit, London, UK, between January, 2013, and December, 2016, we performed skin-sparing mastectomies and nipple-sparing mastectomies with single stage direct-to-implant and ADM reconstruction in 184 patients (288 breasts). Implant loss occurred in ten of 288 breasts (3∙4% loss rate). These data have been prospectively collected and publication is imminent. The 2012 UK oncoplastic breast reconstruction guidelines for best practice2 set the target of implant loss at less than 5%. Darragh and colleagues3 report an overall frequency of implant loss of 1∙9% in 105 breasts with immediate implant-based reconstructions. Sinha and colleagues4 compared 1491 two-stage procedures and 171 one-stage procedures and found a non-significant difference in the overall frequency of major infection (6∙4% one-stage group, 3∙4% two-stage group). Wilkins and colleagues5 compared different breast reconstructions, including implant, expander, and autologous techniques, and reported that failure occurred in 5∙9% of the 1615 implant-based procedures. Dikmans and colleagues1 admit that the surgeons who performed www.thelancet.com/oncology Vol 18 April 2017
ADM-based reconstructions had little experience in this technique. The authors hypothesise that impaired ADM neovascularisation might have affected the survival of the skin flaps. We strongly disagree, and propose that post-surgical viability of the skin flaps is dependent on the adequacy of the subdermal plexus over the preserved native skin envelope. In our experience, skin flap trauma, wound edge ischaemia, or infection-induced hypoxia are the main factors that affect blood supply to the mastectomy flap. We believe that the mastectomy technique and the experience of the surgeon are paramount to the success of this delicate procedure. Although this is the first randomised controlled trial1 to compare one-stage with two-stage implant recon struction, the frequency of implant loss in the study is high and should be interpreted with caution. We feel that direct-to-implant and ADM reconstruction by experienced surgeons in high-volume centres has an established role in immediate breast reconstructions and results in more natural aesthetic outcomes than twostage submuscular reconstructions.
5
Wilkins EG, Hamill JB, Kim HM, et al. Complications in postmastectomy breast reconstruction: one-year outcomes of the mastectomy reconstruction outcomes consortium (MROC) study. Ann Surg 2016; published online Nov 30. DOI:10.1097/ SLA.0000000000002033.
We declare no competing interests.
Tibor Kovacs, *Petros Charalampoudis, Bertha A in ’t Hout, Dorin Dumitru, Ashutosh Kothari [email protected] Breast Unit, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK 1
2
3
4
Dikmans REG, Negenborn VL, Bouman MB, et al. Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial. Lancet Oncol 2017; 18: 251–58. Cutress R, Summerhayes C, Rainsbury R. Guidelines for oncoplastic breast reconstruction. Ann R Coll Surg Engl 2013; 95: 161–62. Darragh L, Robb A, Hardie CM, McDonald S, Valand P, O’Donogue JM. Reducing implant loss rates in immediate breast reconstructions. Breast 2017; 31: 208–13. Sinha I, Pusic AL, Wilkins EG, et al. Late surgical-site infection in immediate implant-based breast reconstruction. Plast Reconstr Surg 2017; 139: 20–28.
e190