Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction.

Abstract

We read with interest the article entitled “Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction,” published in the December of 2020 issue by Winocour et al.1 The study demonstrates that the postoperative seroma rate is higher in robotically assisted latissimus dorsi harvest than in the traditional open approach (16% versus 0%; P = 0.034).1 Seroma is reported to be the most common complication at the latissimus dorsi (LD) flap donor site. The reported incidence ranges from 21% to more than 79%.2 Several factors contribute to formation of the seroma: the thermal injury of electrocautery to the tissue, the disruption of lymphatic vessels and capillaries, the release of inflammatory mediators, and the creation of dead space. Various methods have been described to reduce the dead space, such as closed suction drainage, quilting of the skin flaps, application of adhesive tissue glues, infiltration of steroids or sclerosing agents, and reduction of the use of electrocautery.3 In our experience, seroma is a disabling postoperative sequela that increases the risk of wound infection, dehiscence, and skin flap necrosis, thereby compromising the success of reconstruction. In the traditional open approach, harvest of the LD muscle inevitably comprises the lesion of thoracic lymphatic vessels, which contributes in a fundamental way to the supply of the seroma. For this reason, we perform a reverse lymphatic mapping of dorsal region with Patent Blue solution.4 At the start of surgery, we inject intradermally and subcutaneously five bumps of 0.2 mL of blue dye 2.5% (Bleu Patent V 2.5%, 2 mL; Monico SPA, Venezia/Mestre, Italy) into five locations on the lower dorsal region. Referring to Suami’s study,5 we thought to mark the lymphosome that may have been damaged during flap preparation, injecting in five places on the umbilical line every 4 cm, from the incision to the midline (Fig. 1). At the end, when the LD flap is harvested, we proceed to close the interrupted lymphatic vessels, colored by Patent Blue dye (Fig. 2). Quilting sutures and fibrin glue (Evicel; Omrix Biopharmaceutical, Ltd., Tel Hashomer Ramat Gan, Israel) are used to close the dead space. We use two drains in suction, and we ask the patient not to move the arm for 2 weeks. With this approach, patients have been evidenced a lower incidence of seroma. We consider acceptable the modest increase in operating time in exchange for the shorter hospitalization times and reduced drainage times. In no case was there an adverse reaction to the Patent Blue dye. It is our opinion that higher seroma rates could be due not only to the use of electric endothermy and radiation therapy, but also to the difficulty of performing a careful coagulation of lymphatic vessels that are hardly visible if not colored. The use of Patent Blue dye for lymphatic reverse mapping for ligation of damaged lymphatic vessels has proven to be an effective, economical, and reproducible practice. Prospective studies and more case studies are needed to confirm this hypothesis.Fig. 1.: Intraoperative view of the five injections of Patent Blue dye at the level of the dorsal region.Fig. 2.: Damaged lymphatic vessels previously marked with Patent Blue dye.DISCLOSURE The authors have no financial interests to disclose. No funding was received for this communication. Roberta Albanese, MDNicola Zingaretti, MDGlenda Giorgia Caputo, MDEmanuele Rampino Cordaro, MDPier Camillo Parodi, MDClinic of Plastic and Reconstructive SurgeryDepartment of Medical Area (DAME)Academic Hospital of UdineUniversity of Udine