We thank Drs. Aveta et al. for reporting this case of acute lymphedema of the eyelid after major reconstruction of the medial canthus, which confirms our anatomical findings.1 The authors have described upper eyelid lymphedema occurring as a result of the radical tissue resection around the medial canthus that damaged the inner canthus branch of the lymphatic vessel and the rotational cheek flap that disturbed the outer canthus branch of the lymphatic vessel. The lower eyelid was unaffected because of the presence of the inferior branch of the lymphatic vessel or other anastomotic vessels.
Existing texts describe the lymphatic drainage of the eyelids in two groups: the medial group and the lateral group. The medial group drains to the submandibular nodes and the lateral group drains to the preauricular nodes. The inferior eyelid lymphatic branch has not been described; however, it is represented in diagrams in some articles.2–5 It is important to note that the inferior lymphatic branch of the lower eyelid converges either to the outer or inner canthus lymphatic branches and then drains into the submandibular or preauricular (or parotid) lymph nodes (Fig. 1).
Our study demonstrated that the drainage patterns of the eyelid lymphatics are different from person to person, even on both sides of the same body. We believe that accurate anatomical knowledge of the eyelid lymphatics is the key to surgical management, including cosmetic procedures, trauma, and malignancies such as sentinel lymph node biopsy in this region.
Wei-Ren Pan, M.D., Ph.D.
Cara Michelle Le Roux, B.Biomed.Sc., B.Sc.(Hons.)
Christopher A. Briggs, M.S., Ph.D.
Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Victoria, Australia
1. Pan WR, Le Roux CM, Briggs CA. Variations in the lymphatic drainage pattern of the head and neck: Further anatomic studies and clinical implications. Plast Reconstr Surg. 2011;127:611–620.
2. Sappey PC. Anatomie, Physiologie, Pathologie des vaisseaux lymphatiques. Paris: Adrien Delahaye; 1874.
3. Haagensen CD, Feind CR, Herter FP, et al.. The Lymphatics in Cancer. Philadelphia: Saunders; 1972.
4. Lemke BN, Della Rocca RC. Surgery of the Eyelids and Orbit: An Anatomical Approach. Norwalk, Conn: Appleton & Lange; 1992.
5. Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg. 2008;122:579–586.
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