Subaxillary Replacement Flap Compared with the Round Block Displacement Technique in Oncoplastic Breast Conserving Surgery: Functional Outcomes of a Feasible One Stage Reconstruction

Round 1

Reviewer 1 Report

The manuscript compares two oncoplastic techniques. One is the round block, in which tissue is removed and not replaced, and the other is the replacemet of tissue through a pedicled flap from below the axilla.

The authors have summarised their indications and surgical techniques well, but there are some problems.

The introduction is clearly too long and needs to be shortened. In the description of the round block technique, the NAC is not perfused through "the dermis" but through the underlying plexus and the Würinger septum.

In Figure 1A the image is rotated. In this patient it would probably have been appropriate to perform a bilateral oncoplastic mastopexy. The result would probably have looked better than the unilateral round block technique. 

Figure 2 shows a clear dislocation of the nipple on the right side to the lateral side, if this is the most beautiful picture available of the study group, the question is whether this problem also occurs in other patients due to the incision. The question would be whether this can be avoided by a different incision of the flap, for example by a primary rhomboid flap (Limberg technique).

A major problem of the round block technique is the extension of the NAC. This should also be addressed again in the discussion.

Please correct : "simmetry, sieroma, istance" etc

Author Response

Dear Reviewer,

Thank you for your kind review and cooperation.

I have shortened the introduction as requested to make it more direct and concise.

Certainly the vascularization of the NAC in the Round Block technique depends its posterior glandular base through the underlying plexus and the Würinger septum. I proceeded to change the text to make it clearer in line with your observation. My intention was above all, to specify that a partial incision of the dermis could be advantageous with respect to the possibility of a subsequent nipple sparing mastectomy, but it was not correctly inserted in the text.

With regard to figure 1 I’ve rotated the image correctly, thanks for the note.

Regarding the choice of surgery, I agree with you, but in sharing the surgical project, the patient refused a bilateral approach, expressing her desire for a more conservative procedure. The choice was further confirmed by the prevailing glandular expression as evidenced by the preoperative mammography.

Regarding figure 2, unfortunately this is the best photo available.

It is true that a lateral dislocation of the nipple is appreciated, but it is also true that it represents the image of an early post (1 month). This problem did not occur frequently in the other patients, perhaps also thanks to the elasticity of the skin such as to allow a progressive adjustment over time, and in any case it did not generate strong dissatisfaction.

However, I really appreciate the suggestion to modify the incisional pattern, such as primary rhomboid flap (Limberg technique). The desire to experiment it entirely along the lateral crease derived from the desire to propose a single incisional line along this anatomical subunit (a hypothesis that I’ve considered attractive). However, I will try to further improve the technique in the future according to your suggestions.

I also proceeded to point out the late-onset scar widening and changes in the areola shape in the discussion, an aspect which is always important and which requires caution in the surgical technique.

I've corrected the spelling errors you reported and corrected the punctuation, thanks.

In conclusion, thank you very much for all the valuable observations you have made to this paper, since they have been a source of further enrichment and reflection for me.

with regard

Paolo Orsaria

Reviewer 2 Report

I read with interest the article of Orsaria et al. about comparison between sub-axillary replacement flap and round block displacement technique in oncoplastic breast conserving surgery. 

I found it well written, the English is good and the text is clear and easy to understand.

Even if the numbers are not high and the techniques are not innovative, it is an interesting study.

I noticed an error in photo 1A where the patient's image is mirrored.

I recommend this article with this minor review.

Author Response

Dear Reviewer,

Thank you for your kind review and cooperation.

With regard to figure 1 I’ve rotated the image correctly, thanks for the note.

I also proceeded to point out the late-onset scar widening and changes in the areola shape in the discussion, an aspect which is always important and which requires caution in the surgical technique.

I've corrected some spelling errors reported and the punctuation, thanks.

Thank you very much for all the valuable observations you have made to this paper, since they have been a source of further enrichment and reflection for me.

with regard

Paolo Orsaria