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• W4318025401 abstract "I would like to congratulate the authors on their potential innovation to prevent seromas following harvest of the latissimus dorsi (LD) muscle, as described in their comment regarding my recent publication.1 As the authors state, seroma is one of the more common and difficult to manage complications of LD harvest due to a variety of factors, including a large dead space, monothermy use over a broad area, divided lymphatics, and an anatomic region subject to constant mobile forces. Reverse lymphatic mapping followed by either avoiding or ligating cut lymphatics could lead to a powerful reduction in seroma formation following LD harvest. Although this innovation is an excellent start, the authors fall short of maximizing the complete benefit of this strategy. There will certainly be divided ends of lymphatics whose flow can be halted by ligation. However, this will still lead to backup of fluid into the interstitium. Instead of simple ligation, why not find a neighboring cutaneous vein and perform a formal lymphovenous bypass? This would have the dual effect of preventing unfettered outflow from the cut lymphatic into the donor site and diverting this flow into the venous system to return to circulation. It seems to me that this would be an even greater advance in seroma prevention and would also be more physiologic. Even with this addition, there is yet another level to take this concept to maximize its true potential. When an LD is dissected up to its insertion to isolate the vascular pedicle, dissection occurs in the axilla, where most of the lymph nodes that drain the arm, flank, and upper back reside. There are also a plethora of venous targets in this area, including branches of the thoracodorsal, such as the serratus branch, skin perforators, the lateral thoracic vessels, and various intercostals. If reverse lymphatic mapping is being performed, these lymphatics would presumably light up blue and be larger and more confluent targets for lymphovenous bypass than the peripheral lymphatics, making them potentially more effective in lymphedema prevention. This is precisely the way in which we perform reverse lymphatic mapping of the arm before prophylactic lymphovenous bypass following axillary clearance to prevent lymphedema following breast cancer.2–6 There is no reason why a similar approach couldn’t be taken for the LD flap and its lymphosome. In fact, one could map the back and the arm at once to be sure that the surgeon performing the operation lived up to the oath to first do no harm. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. Jesse C. Selber, MDUniversity of Texas M.D. Anderson Cancer Center1400 Pressler Drive, Unit 1488Houston, TX 770030[email protected]" @default.
• W4318025401 created "2023-01-26" @default.
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• W4318025401 date "2022-11-15" @default.
• W4318025401 modified "2023-10-18" @default.
• W4318025401 title "Reply: Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction" @default.
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• W4318025401 doi "https://doi.org/10.1097/prs.0000000000009869" @default.
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