Medial Row Perforators Are Associated with Higher Rates of Fat Necrosis in Bilateral DIEP Flap Breast Reconstruction
First, the authors evaluated the incidence of fat necrosis in bilateral breast reconstruction using the deep inferior epigastric perforator flap at 3 months after surgery. However, the location of the fat necrosis is not mentioned. Because of the different flap perfusion between the medial row group and lateral row group, as the authors stated, the location of the fat necrosis may vary from group to group. If the authors can analyze the fat necrosis based on its location, the association between fat necrosis and perforator location will be more persuasive.
Second, in this article, the authors diagnosed fat necrosis by physical examination. Although it may be a conventional way to diagnose fat necrosis, it is necessarily subjective and depends somewhat on the examiner’s diligence. Thus, the result may be biased by the examiners. It will be much better to add some objective indicator such as magnetic resonance imaging or ultrasound in a future study to evaluate fat necrosis.
Third, in terms of preoperative variables, the body mass index was statistically significant among the three groups (p = 0.008) (Table 1 in the article by Kamali et al.). Although the correlation between body mass index and rates of fat necrosis was inconsistent, body mass index is an important preoperative variable because some studies stated that obesity was associated with a higher incidence of fat necrosis.2 Thus, it may be necessary to analyze the association between body mass index and fat necrosis in this study.