We read with interest the article entitled “Breast Reconstruction and Lymphedema” (Plast Reconstr Surg. 2010;125:19–23). We would like to congratulate Dr. Chang and Dr. Kim for their publication, reporting the low incidence of lymphedema following delayed autologous breast reconstruction and the likelihood of improvement in postmastectomy upper limb lymphedema following autologous ipsilateral breast reconstruction.
The number of patients in the series is impressive. However, details regarding the cause of the lymphedema are not clear. In the postmastectomy lymphoedema group, there is mention that 36 of the 38 patients had undergone an axillary node dissection and 32 had received radiotherapy. In the nonlymphedema group (482 patients), 324 had previous axillary dissection and 222 had preoperative radiotherapy. It has not been specified which patients had both of these procedures and whether the 16 patients who subsequently developed lymphedema had undergone either or both.
The authors have used the statistical test (Fisher's test) to compare groups of patients with only a single variable (e.g., previous radiotherapy or axillary dissection) as a cause for lymphedema. The cause of lymphedema being multifactorial, the analysis should have taken into account patients who had both axillary dissection and radiotherapy.
The period from mastectomy to reconstruction in the lymphedema group ranged from 8 to 402 months (mean, 30 months) and the period from radiotherapy to reconstruction in the same group has been quoted as 6 to 81 months (mean, 17 months). The article states that the patients were seen by certified lymphedema therapists. It is not specified, however, whether patients received conservative lymphedema therapy [e.g., upper limb exercises, simple lymphatic drainage, compression hosiery, decongestive lymphatic therapy, manual lymphatic drainage, sequential pneumatic compression, or Kinesio tape] during this time and whether this improved the lymphedema. The authors accept that the lack of objective assessment of lymphedema is a drawback but do not describe their technique for lymphedema assessment. It is also not stated whether this therapy was continued after the reconstruction. There is also no mention of the follow-up duration after breast reconstruction. Thus, the lack of objective assessment combined with the lack of information regarding conservative therapy and follow-up duration makes it difficult to decipher whether the lymphedema resolved progressively with time, with conservative therapy secondary to a flap reconstruction.
We compliment the authors on the impressive number of patients included in their series but feel that the number of patients with lymphedema is small (38 patients) for making statistical conclusions. The authors' overall conclusions bring to light the positive effect of autologous breast reconstruction on upper limb lymphedema and support the earlier work of Kambayashi et al. We feel that prospective studies and more focused research into mapping of upper limb lymphatic channels following autologous breast reconstruction are warranted to provide further collaborative evidence to support the authors' conclusions. We would also like to thank the Editor for the opportunity to share our thoughts on this article.
Muhammad Adil A. Khan, M.R.C.S.
Karthikeyan Srinivasan, F.R.C.S.
Arvind Mohan, M.B.B.S.
Joseph Hardwicke, Ph.D., M.R.C.S.(Eng.)
Sukhbir Rayatt, F.R.C.S.(Plast.)
University Hospital of North Staffordshire NHS Trust
Stoke-on-Trent, Staffordshire, United Kingdom
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