Letter to the Editor
Response to “Comments on ‘Maximizing the
Volume of Latissimus Dorsi Flap in Autologous
Breast Reconstruction with Simultaneous
Multisite Fat Grafting’”
Aesthetic Surgery Journal
2016, Vol 36(7) NP239–NP241
© 2016 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
[email protected]
DOI: 10.1093/asj/sjw071
www.aestheticsurgeryjournal.com
Lin Zhu, MD; Anita T. Mohan, MRCS, MBBS, BSc; Aparna Vijayasekaran,
MBBS; Christine Hou, BSc; Yoo Joon Sur, MD, PhD; Mohamed Morsy,
MBBCh, MSc; and Michel Saint-Cyr, MD, FRCS(C)
Accepted for publication March 28, 2016; online publish-ahead-of-print April 26, 2016.
We would like to thank Drs Niddam and Meningaud1 for
their interest in our paper entitled “Maximizing the Volume
of Latissimus Dorsi Flap in Autologous Breast Reconstruction
with Simultaneous Multisite Fat Grafting.”2
The decision to perform additional fat grafting following
the initial reconstruction is multi-factorial and based on individual patient characteristics and expectations. We
always try to harvest the largest skin area possible in order
to maximize not only immediate available volume, but also
a larger surface area to fat graft into. For the same reasons,
the entire latissimus muscle (LD) is harvested. Patients
with a relatively high body mass index (BMI) and large fat
compartments in the back may not require very much fat
grafting both primarily or secondarily. Factors such as;
patient BMI, available skin paddle size, LD muscle thickness, previous radiation therapy, thickness of the mastectomy skin flap, timing of reconstruction, size of the ideal
contralateral breast and reconstructed breast, and patient
expectations, all play a part in our decision to perform or
not additional fat grafting secondarily.
Postoperatively, all flaps were monitored based on clinical
evaluation, using color, capillary refill, turgor, and Doppler
arterial signal when available. Our average follow-up duration was 14.3 months (range, 6-30 months), which was suitable for evaluation of longer-term fat grafting survival.
Endpoints simply included whether patients were happy
with their final result, and additional fat grafting was performed as needed (3/10 patients in this series). Our results
imply that in 70% of cases a single stage reconstruction
was required only. Additional fat grafting was performed
between three and six months following the initial reconstruction. We also agree with the authors and favor waiting
up to six months in order to evaluate final fat grafting survival and any further surgery and fat grafting.
There was no clinically detectable fat necrosis in this
series which may be explained by the following: multiple
recipient sites available for fat grafting, smaller volumes
used for each fat grafted site, excellent recipient site blood
supply, ideal fat graft-to-recipient site volume ratio. All of
these factors may enhance fat grafting survival. In order to
conserve costs, we do not routinely use magnetic resonance
imaging to assess fat grafting survival.
Dr Zhu is an Attending Surgeon, Department of Plastic Surgery, Peking
Union Medical College Hospital, Beijing, China, and a Research Fellow,
Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
Dr Mohan is a Resident. Restoration of Appearance and Function
Charitable Trust (RAFT), Middlesex, UK; and a Research Fellow,
Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
Dr Vijayasekaran is a Resident, Drs Sur and Morsy are Research
Fellows, and Dr Saint-Cyr is a Professor, Division of Plastic Surgery,
Mayo Clinic, Rochester, MN, USA. Ms Hou is a Medical Student, Mayo
Medical School, Rochester, MN, USA.
Corresponding Author:
Dr Michel Saint-Cyr, Division of Plastic Surgery, Wigley Professorship
in Plastic Surgery, Baylor, Scott and White Health 2401 S, 31st Street,
Temple, TX 76508, USA.
E-mail: [email protected]
Aesthetic Surgery Journal 36(7)
NP240
Figure 1. (A, C) Preoperative photographs of this 54-year-old woman show the bilateral latissimus dorsi flap donor sites. (B, D)
Three month postoperative photographs after bilateral breast reconstruction with fat grafted latissimus dorsi flaps, with anticipated
NAC and revision surgery.
All skin paddles were harvested along the patient
normal resting tension line in the back. This would usually
fall within the bra line and incorporated as many fat compartments in the back (lower thoracic and upper lumbar fat
compartments).3 A “double bubble pinch test” was used to
mark the largest skin paddle between two fat compartments in the back. Subcutaneous tissue undermining was
limited to the periphery of the skin paddle only in order to
avoid step off deformities between the skin paddle and
muscle. This area of undermining was also amenable to fat
grafting for more volume. In order to limit donor site morbidity, no additional fat harvest or undermining were performed. All donor sites were closed using a combination of
progressive tension sutures and quilting sutures to minimize
empty space and closing tension. There were no seromas in
this series using this technique. This original article was
limited in the number of images allowed therefore we have
included additional images in our reply (Figure 1).
The term overcorrection requires definition. We define
overcorrection as the ideal volume of fat grafting in each recipient site, over multiple sites, in order to achieve stable
long-term results. In the majority of cases the ideal volume
of fat was grafted in as many recipient sites as possible to
achieve final outcome. None of the individual sites were
grafted beyond their recipient capacities. This may explain
our absence of fat necrosis. We believe that muscle represents an excellent recipient carrier for fat grafting. Well visualized and selective muscle fat grafting (latissimus dorsi,
pectoralis, serratus + fascia) is simple and reliable in the
immediate setting.
This technique has the advantage of avoiding implants
and keeping the breast reconstruction purely autologous.
We agree with the authors that a multicenter long-term
trial would be ideal and we are certainly open to future
collaborations.
Disclosures
Dr Zhu was financially supported by the China Scholarship
Council for a research fellowship and Dr. Mohan was financially
supported by the Blond Royal College of Surgeons of England
Research Fellowship 2015 as a research fellow. Dr Saint-Cyr is a
Consultant for Mentor (Santa Barbara, CA), Allergan (Irvine,
Zhu et al
CA), LifeCell (Bridgewater, NJ), and Pacira Pharmaceuticals, Inc.
(Parsippany, NJ). The other authors have nothing to disclose.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
1.
Niddam J, Meningaud JP. Comments on “Maximizing the
volume of latissimus dorsi flap in autologous breast recon-
NP241
struction with simultaneous multisite fat grafting”. Aesthet
Surg J. 2016;36(7):NP237–NP238.
2. Zhu L, Mohan AT, Vijayasekaran A, et al. Maximizing the
volume of latissimus dorsi flap in autologous breast reconstruction with simultaneous multisite fat grafting. Aesthet
Surg J. 2016;36(2):169-178.
3. Bailey SH, Saint-Cyr M, Oni G, et al. The low transverse
extended latissimus dorsi flap based on fat compartments
of the back for breast reconstruction: anatomical study
and clinical results. Plast Reconstr Surg. 2011;128(5):
382e-394e.