Skip Navigation LinksHome > June 2014 - Volume 133 - Issue 6 > Reply: A Prospective Analysis of 100 Consecutive Lymphoveno...
Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0000000000000209
Letters

Reply: A Prospective Analysis of 100 Consecutive Lymphovenous Bypass Cases for Treatment of Extremity Lymphedema

Chang, David W. M.D.; Suami, Hiroo M.D., Ph.D.; Skoracki, Roman M.D.

Free Access
Article Outline
Collapse Box

Author Information

Section of Plastic and Reconstructive Surgery, Department of Surgery, Medicine and Biological SciencesThe University of Chicago, Chicago, Ill.

Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas

Correspondence to Dr. Chang, Section of Plastic and Reconstructive Surgery, Department of Surgery, Medicine and Biological Sciences The University of Chicago, 5841 South Maryland Avenue, Room J641, MC 6035, Chicago, Ill. 60637 dchang@surgery.bsd.uchicago.edu

Back to Top | Article Outline

Sir:

We would like to thank Drs. Yamamoto and Koshima for their insightful comments. We agree that what is critically important is to precisely identify functioning lymphatic vessels for lymphovenous bypass. We are aware that the lymphatic vessels do run along the great saphenous and cephalic vein; these are called the median or medial bundle.1 However, these lymphatic vessels are not always detected during indocyanine green lymphography, meaning that they are not always functional in certain lymphedema patients. We speculate that in these patients the associated lymph nodes or the proximal portion of the medial lymphatic bundle were excised or damaged during the axillary or inguinal dissection. Thus, just relying on our knowledge of lymphatic anatomy alone is not sufficient for identifying optimal lymphatic vessels for bypass.

We have found that the best way to identify functioning lymphatic vessels for lymphovenous bypass is to perform indocyanine green fluorescence lymphography and mapping of the functioning lymphatic vessels just before surgery. As soon as the indocyanine green is injected, fluorescent images of the functioning lymphatic vessels can be visualized using a Hamamatsu Photodynamic Eye (Hamamatsu Photonics, Hamamatsu, Japan), and the mapping is performed on the skin surface immediately. As time passes, even after just 10 to 15 minutes, indocyanine green dye refluxes into the superficial and subdermal lymphatics of the limb, creating the various patterns of dermal backflow, as described by Drs. Yamamoto and Koshima. Once this occurs, the linear patterns of functioning lymphatic vessels often are no longer visible, as they are overshadowed by dermal backflow.

We agree with Drs. Yamamoto and Koshima that the type of dermal backflow is important for staging, but we have found in our experience that the quality and the quantity of functioning lymphatic vessels identified by indocyanine green fluorescence lymphography just before surgery not only facilitate the operation but are among the key factors in determining the outcome following lymphovenous bypass.

Back to Top | Article Outline

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

David W. Chang, M.D.

Section of Plastic and Reconstructive Surgery

Department of Surgery

Medicine and Biological Sciences

The University of Chicago

Chicago, Ill.

Hiroo Suami, M.D., Ph.D.

Roman Skoracki, M.D.

Department of Plastic Surgery

The University of Texas M. D. Anderson Cancer Center

Houston, Texas

Back to Top | Article Outline

REFERENCE

1. Kubik S, Kretz O. Anatomy of the lymphatic system. Földi’s Textbook of Lymphology. 2006 Munich Elsevier GmbH:1–149

Back to Top | Article Outline
GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2014American Society of Plastic Surgeons

Login

Article Tools

Share


The Clinical Masters of PRS – Breast eBooks
4 Essential eBooks for Plastic Surgeons