Sir: We appreciate the interest that Dr. Antonio Araco and his colleagues have taken in our article,1 and we thank them for their insightful comments and stimulating questions. As they have noted, massive weight loss patients appear to have a high morbidity rate following abdominoplasty or other body contouring procedures. This observation has been shared by several others.2–6 Specifically, many have found an increased seroma rate in their operative experience with this patient population.7,8 However, the roles of body mass index, weight loss, and other clinical factors in the complication rate remain incompletely understood. In our series, we did treat a number of patients who had lost a significant amount of weight before presenting for their initial surgical consultation, but we must note that our patient population did have a fairly uniform body mass index at the time of surgery, averaging 24 kg/m2. Although our experience certainly does not compare with others with a significant body contouring patient population, we would suggest that preservation of the suprafascial layer containing what we believe to be a lymphatic-rich plane could be just as beneficial in reducing the seroma rate in massive weight loss patients as compared with nonobese patients. However, we acknowledge that the factors leading to postoperative seroma in massive weight loss patients may not be analogous to nonobese patients and that the microanatomy of the suprafascial tissue plane may also be markedly altered. Although we agree with Dr. Araco that a thin skin flap from a more superficial dissection could predispose to necrosis in the event of a large hematoma or seroma, we should clarify that the layer of tissue that we have preserved with our technique is a thin areolar layer just superficial to the abdominal wall muscular fascia. Thus, we have found that the change in the thickness of the skin flap when using this dissection plane is rather insignificant. In patients with more adipose tissue along the abdominal wall, this plane typically lies well beneath the Scarpa fascia and the vascular plexus of the skin. In our approach to the weight loss patient, we believe that preservation of as many of the skin perforators laterally and superiorly as possible is certainly essential for reducing the risk of necrosis. The combination of tumescence with sharp dissection allows us to identify and preserve these perforators during skin flap elevation. We limit dissection superiorly and laterally more so than in the nonobese patient, and we close under considerable tension to allow adequate skin resection. Although there have been multiple clinical investigations that have analyzed potential factors affecting the postoperative complication rate in massive weight loss patients, there remains a paucity of studies exploring the anatomy and physiology of seroma formation in both the nonobese and massive weight loss populations. In the recent literature, we have noted a handful of studies focusing on the changes of the skin structure after massive weight loss, the composition of seroma fluid, and anatomy of abdominal wall lymphatics.9–13 Such continued pursuits will be needed to further elucidate the physiology of our findings and other similar clinical observations that have been reported in the contemporary literature. Thomas A. Mustoe, M.D. Robert C. Fang, M.D. Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, Ill. Samuel J. Lin, M.D. Division of Plastic Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, Mass.