We read with great interest the article by M-H Cheng et al.1 entitled “Vascularized Groin Lymph Node Flap Transfer for Postmastectomy Upper Limb Lymphedema: Flap Anatomy, Recipient Sites, and Outcomes.” We congratulate the authors on their good surgical results and their detailed anatomical reviews using cadavers. Among all the options for the surgical treatment of lymphedema, vascularized lymph node transfer is, indeed, the most promising. Herein, we have some comments on the surgical techniques.
In their article, the authors treated upper extremity lymphedema by transferring a vascularized groin lymph node flap to the elbow or wrist. It seems that they anastomosed the vessels of the flap with the superficial venous system. We think it would be more appropriate to use the deep venous system for a couple of reasons:
- The deep venous system is usually more reliable than the superficial one.2
- The superficial veins might be injured if a debulky or excisional procedure is performed in the future. Simple de-epithelialization is not good enough cosmetically.
The only drawback with applying the deep venous anastomosis is the caliber discrepancy, which, however, can be easily overcome using hand-sewn techniques. To prevent the problem of bulkiness, a vascularized lymph node flap based on the perforators is applicable.3 Alternatively, we can carry the flap without a skin paddle, even though the flap monitoring is a big issue.
Nevertheless, we still have a long-long way to go before winning the battle against postmastectomy lymphedema.
The authors have no financial interest to declare in relation to the content of this communication.
Yi Poon, M.D.
Department of Plastic Surgery
Changhua Christian Hospital
Ching-Yueh Wei, M.D.
Department of Plastic Surgery
Cheng Ching General Hospital
1. Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013;131:1286–1298
2. Lorenzo AR, Lin CH, Lin CH, et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: Analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg. 2011;64:649–655
3. Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg. 2011;67:589–593
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