Secondary Logo

Journal Logo

Reply: Operative Treatment of Peripheral Lymphedema A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplant

Basta, Marten N. B.S.; Gao, Lin Lin M.D.; Wu, Liza M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 492e–493e
doi: 10.1097/PRS.0000000000000436

Plastic and Reconstructive Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, Pa.

Correspondence to Marten N. Basta, Plastic and Reconstructive Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 10 Penn Tower, Philadelphia, Pa. 19104,

Back to Top | Article Outline


We greatly appreciate Dr. Assaf Zeltzer’s commentary about our recently published article, “Operative Treatment of Peripheral Lymphedema: A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplant.”1 Several observations are highlighted that deserve further discussion.

It is duly noted that comparing lymphovenous shunt procedures with vascularized lymph node transplant procedures is replete with limitations. There are differences between the lymphovenous shunt studies, including variations in the vessels being anastomosed and the configuration of those anastomoses. Furthermore, the five lymph node transplant studies do use different vascularized flaps and different recipient sites. As such, the primary outcome of our review was not a head-to-head comparison of outcomes by technique. Instead, we compared the quantitative change in lymphedema preoperatively versus postoperatively across all techniques to assess efficacy. Our secondary outcomes included subgroup comparisons of efficacy by operative technique and anatomical site of lymphedema. It is essential that the reader takes into consideration the variability of operative techniques when evaluating the subgroup results.

Another observation is the variability of reported complication rates by technique. Although we found generally low rates of complications regardless of technique, the only conclusion we can draw based on our results, unfortunately, is that there are significant deficiencies in complications reporting among the lymphovenous shunt studies. Regarding vascularized lymph node transplant studies, the follow-up period was insufficient in each study to determine an accurate assessment of donor-site complications. Indeed, donor-site lymphedema is the dreaded complication of vascularized lymph node transplant, from the surgeon’s perspective and from the patient’s perspective.2–4

Moving forward, we hope that our systematic review not only provides valuable information regarding the safety and efficacy of microsurgical treatment of lymphedema but also encourages stricter adherence to the International Society of Lymphology’s guidelines for assessing lymphedema and improved reporting of outcomes and complications.5 Until more accurate information is available regarding donor-site complications using vascularized lymph node transplantation, our results should be interpreted with great caution, particularly by young microsurgeons at the inception of their training.

Back to Top | Article Outline


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

Marten N. Basta, B.S.

Lin Lin Gao, M.D.

Liza Wu, M.D.

Plastic and Reconstructive Surgery

Perelman School of Medicine

University of Pennsylvania Health System

Philadelphia, Pa.

Back to Top | Article Outline


1. Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: A systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplant. Plast Reconstr Surg. 2014;133:905–913
2. Pons G, Masia J, Loschi P, Nardulli ML, Duch J. A case of donor-site lymphoedema after lymph node-superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg. 2014;67:119–123
3. Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg. 2013;45:516–520
4. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg. 2012;130:1246–1253
5. International Society of Lymphology. . The diagnosis and treatment of peripheral lymphedema: 2009 consensus document of the International Society of Lymphology. Lymphology. 2009;42:51–60
Back to Top | Article Outline


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

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