Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction

We read with great interest the article entitled “Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction” by Winocour et al.1 Since the Food and Drug Administration approved the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, Calif.) in 2000, robotic assistance has been widely adopted across multiple specialties. We are glad to see its use in plastic and reconstructive surgery. The latissimus dorsi muscle flap is the most commonly performed procedure in plastic surgery.2 The biggest problem is that the open latissimus dorsi muscle flap harvest approach leaves a long and unexpected scar on the back, which compromises the aesthetic outcome and patient satisfaction. The authors used the novel, minimally invasive technique of the da Vinci surgical robotic platform to improve cosmetic outcomes. However, in our opinion, the da Vinci platform and traditional open surgery are not comparable to one another. The traditional technique has the merit of harvesting skin paddles, which could provide more volume and skin coverage to the breast for patients. While the advantages of surgical robots often show up in a deep complex cavity, they are only indicated when a muscle paddle is needed. Therefore, we think a comparison between the da Vinci platform and the endoscope would make more sense. Since the 1990s, endoscopic techniques have been developed to harvest latissimus dorsi muscle flaps for reconstruction purposes.3 The creation of a suitable cavity for tissue dissection with poorly maneuverable instruments was a limitation. Recently, however, the transaxillary endoscopic technique was introduced to perform breast reconstruction with the latissimus dorsi myocutaneous flap, which was conducive to reducing scar length and concealing scar location.4 The robotic surgical system as a minimally invasive technique is more advanced than the endoscope. A real-time, high-definition, three-dimensional optic of the robotic approach provides a superior image and eliminates surgeons’ tremors for highly accurate dissection, which has placed great expectations for improvement on intraoperative bleeding, donor-site scar, hospital stay, patient satisfaction, and postoperative complications. Meanwhile, it is important to mention that the robotically assisted latissimus dorsi muscle flap harvest is an expensive and time-consuming option, and these costs must be balanced with the benefits. DISCLOSURE The authors have no financial interest to declare in relation to the content of this study. No funding was received for this communication. Zixuan Zhang, M.D.Ziying Zhang, M.D.Minqiang Xin, M.D.Department of Aesthetic and Reconstructive Breast SurgeryPlastic Surgery HospitalChinese Academy of Medical SciencesPeking Union Medical CollegeBeijing, People’s Republic of China