Autologous Latissimus Dorsi Flap as an Alternative to Free Abdomen-Based Flap for Breast Reconstruction in the Morbidly Obese

Abstract

Sir:FigureIt was with great pleasure that we read the article by Jandali et al.1 entitled “Breast Reconstruction with Free Tissue Transfer from the Abdomen in the Morbidly Obese,” and we congratulate the authors on their interesting study. Breast reconstruction in overweight and obese patients represents a difficult challenge for plastic surgeons, who remain guarded over selecting these patients for free abdominal tissue transfer. Although higher complication rates have been reported by Jandali et al. in these patients, obesity does not constitute an automatic contraindication for free abdomen-based flap breast reconstruction (Fig. 1).Fig. 1: Preoperative and postoperative views of a 43-year-old patient, with a body mass index of 40.9, who underwent delayed left breast reconstruction with an autologous latissimus dorsi flap and contralateral reduction mammaplasty. A significant volume of fat was included in the autologous latissimus dorsi flap, which gave bulk to the breast without the aid of a prosthesis, producing a natural reconstructed breast.Recently, Seidenstuecker et al.2 investigated the relevance of comorbid conditions such as age 65 years or older, active smoking, and body mass index greater than 30 on free flap breast reconstruction, and they similarly reported higher total flap loss and delayed donor-site wound healing in obese patients. We would like to take the opportunity to discuss the indications and advantages of the autologous latissimus dorsi flap breast reconstruction in morbidly obese patients, which may present a valid option for these patients. The autologous latissimus dorsi flap is a well-vascularized flap that is safe, versatile, and reliable, with a very high success rate.3 For these reasons, it is also suitable for high-risk patients, such as obese patients, smokers, diabetics, and patients of advanced age. Compared with the standard latissimus dorsi flap with implant, the autologous latissimus dorsi flap is capable of delivering a significant volume of fat, which gives bulk to the breast without the aid of a prosthesis. If the flap volume is then not sufficient, it can be improved by fat injection (lipomodeling). Nevertheless, the autologous latissimus dorsi flap is a major operation, it is less involved than free tissue transfer, and it requires no microsurgical skills or any intensive postoperative flap monitoring as in free flaps. Transfer of the latissimus dorsi muscle minimally impairs shoulder function, inducing little detectable change in the range of motion and muscular strength, and functional sequelae are minimized by compensation by means of the teres major muscle.4 It is well known that donor-site seroma is a drawback of this technique; however, numerous treatments and preventive measures have been described to reduce this problem. These include avoidance of electrocautery for dissection, the use of quilting sutures, fibrin sealant, endoscopic harvest, long-term distant exit drainage, and pressure dressings.5,6 In our experience, quilting stitches combined with fibrin sealant significantly reduced postoperative seroma. Despite this drawback, we believe that the autologous latissimus dorsi flap is a good option in obese patients despite the relatively high incidence of back seroma, which is for us a minor complication, treatable on an outpatient basis, and with a lower impact compared with a total flap loss or an abdominal bulge, weakness, or hernia following an abdominal flap. Stefano Bonomi, M.D. Andrè Salval, M.D. Fernanda Settembrini, M.D. Chiara Gregorelli, M.D. Gaetano Musumarra, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.