Reply: Medial Row Perforators Are Associated with Higher Rates of Fat Necrosis in Bilateral DIEP Flap Breast Reconstruction

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We thank Drs. Wang and Luan for their interest in our study entitled “Medial Row Perforators Are Associated with Higher Rates of Fat Necrosis in Bilateral DIEP Flap Breast Reconstruction.”1 In their letter, they critically reviewed and commented on a few points: the location, the method of diagnosis, and the role of body mass index in the occurrence of fat necrosis.
As stated in our study, because of the different flap perfusion between the medial row group and the lateral row group, the location of the fat necrosis may vary between groups. Future studies are indeed needed to provide more specific and granular information with regard to the differences in perfusion between the lateral and medial row. However, in this study, we decided not to focus on the location of the fat necrosis, because bilateral flaps are divided along the midline and the perforators are therefore entirely ipsilateral. Consequently, the perforators do not cross the midline. In our institution, we use physical examination as a standard for method of diagnosis simply because when and if fat necrosis can be palpated through physical examination, it is clinically significant to the patient. Although magnetic resonance imaging or ultrasound examinations would identify all instances of fat necrosis, we did not include all fat necroses in this study but included only those of clinical significance. Lastly, as Dr. Wang and Dr. Luan noted correctly, the lateral-based group (28.2 ± 4.7 kg/m2) does have a lower body mass index than the medial group (29.2 ± 5.7 kg/m2) versus the medial/lateral group (29.7 ± 5.8 kg/m2). However, the fat necrosis rates comparing the medial/lateral group are similar to fat necrosis rates of the lateral-based group (8.2 percent versus 11.6 percent; p = 0.203). For this reason, the lower body mass index in the lateral-based groups is not a contributing factor because the medial/lateral group has the highest body mass index. We thank Drs. Wang and Luan for their thoughtful comments on our article.

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