Scarless Donor Site for Breast Reconstruction by Endoscopically Assisted Extended Latissimus Dorsi Flap plus Lipofilling

We read with great interest the article by Akita et al. on endoscopic harvesting of the latissimus dorsi (LD) muscle flap combined with fat transfer for breast reconstruction.1 We have used a similar technique over the past 18 years2,3 and would like to share some points that might be interesting for the reader. The endoscopically assisted LD muscle flap presents several advantages, including shortened hospital stay, decreased postoperative pain, and limited incisions.2 Some of these advantages have been discussed in the literature. Postoperative pain has been reported to be comparable in both open and endoscopic techniques.4 The advantages of the smaller scar have also been called into question.4 Consequently, after the initial enthusiasm, endoscopic LD harvesting could not gain enough popularity because of several drawbacks—essentially, technical difficulties independent of the indications. First, it seems difficult to create an adequate optical cavity because of the lack of sufficient elasticity of the skin and soft tissues, unlike in laparoscopic surgery. In our hands, this was the most important problem to solve. External traction (traction sutures), internal retraction by retractors and/or saline-filled balloon retractors, the combination of both, and insufflation of carbon dioxide1–5 were all used. It is still difficult to evaluate the best method to create a convenient optic space for LD flap harvesting, and it depends on the surgeon’s experience. The second point concerns hemostasis and muscle sectioning. With the classic bipolar and monopolar endoscopic cauterization, the percentage of revision for bleeding has been reported to be as high as 4%.4,5 Furthermore, the risk for damaging the overlying skin when dissecting the subcutaneous space is increased. The ultrasound endoscopic scalpel and electrothermal bipolar vessel sealer were reported as useful options. We have successfully used2 ultrascision, as reported by Akita et al.1 The third point is the seroma formation in the donor site, which is common after LD muscle harvesting and may be a difficult-to-treat complication.5 Akita et al. used a 10 × 10-cm piece of polyglycolic acid fabric to promote adhesion.1 We use quilting sutures in the open approach or external compression (compressive bands) in the endoscopic approach to prevent it. Finally, the volume of the muscle LD flap may be a limiting factor.1 However, fat grafting offers an extra tool for increasing its volume. In this sense, we have injected more than 200 cc in the LD muscle flap, the pectoralis major muscle flap, and skin flaps, with no complications. However, in single-stage reconstruction, we avoid injecting the skin flaps because of the risk of vascular compromise. In our practice, we do not section the thoracodorsal nerve because of the potential risk of flap volume loss. In conclusion, with broadening of the indications of skin-sparing and subcutaneous mastectomy, the endoscopic LD flap technique will probably gain increasing importance in association with fat grafting. However, the technical difficulties in dissecting the LD flap are not entirely resolved. In this regard, we thank Akita et al. for their important contribution and efforts in improving breast reconstruction techniques. DISCLOSURE The authors have no financial or nonfinancial interests to declare in relation to the content of this communication. The authors declare no relationships, activities, or interests; no funding; and no provision of study materials, medical writing, or article-processing charges in relation to this work.