Volume 134, Number 3 • Letters We describe these additional techniques in order to optimize management and to provide more donor-site choices that are not based on surgeon preference. DOI: 10.1097/PRS.0000000000000479

Lin Fang, M.D. Chen Zhang, B.S. Lianzhao Wang, M.D. Microinvasive Department of Plastic Surgery Plastic Surgery Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Wang Microinvasive Department of Plastic Surgery Plastic Surgery Hospital Chinese Academy of Medical Sciences Peking Union Medical College No. 33, Ba-Da-Chu Road Beijing 100144, People’s Republic of China [email protected]

PATIENT CONSENT The patient provided written consent for use of the patient’s image. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Zan T, Li H, Bu B, et al. Surgical treatment of facial softtissue deformities in postburn patients: A proposed classification based on a retrospective study. Plast Reconstr Surg. 2013;132:1001e–1004e. 2. Margulis A, Amar D, Billig A, Adler N. Periorbital reconstruction with the expanded pedicled forehead flap. Ann Plast Surg. ePub ahead of print; July 30, 2013:doi:10.1097/ SAP.0b013e3182978a29. 3. Gan C, Fan J, Liu L, et al. Reconstruction of large unilateral hemi-facial scar contractures with supercharged expanded forehead flaps based on the anterofrontal superficial temporal vessels. J Plast Reconstr Aesthet Surg. 2013;66:1470–1476. 4. Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: Anatomical basis of a new flap donor site. Surg Radiol Anat. 2013;35:39–48. 5. Hofer SO, Mureau MA. Pedicled perforator flaps in the head and neck. Clin Plast Surg. 2010;37:627–640, vi.

Operative Treatment of Peripheral Lymphedema: A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplant Sir: urgical treatment of lymphedema has been one of our main points of interest for more than 5 years. Therefore, we are very pleased to read an article concerning this complex abnormality and the choice of technique.1

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We note that the article is a meta-analysis, which has limitations, some of which the authors have stated and addressed; however, we have some reservations about the studies compared in this article. The authors have included two different techniques in their analysis (lymphaticovenous anastomosis and lymph node transfer) but, in reality, the group is much more heterogenous than pictured. First, there is an “imbalance” in the number of studies included in each group (22 lymphaticovenous anastomosis versus five lymph node transfer articles). In the lymphaticovenous anastomosis group, both “real” lymphaticovenous anastomosis and lymph vessel transplantations have been included. These derivative procedures cannot be thrown into the same group, as the technique is completely different. In the classic lymphaticovenous anastomosis group, derivation is performed between the lymphatic system and the venous system, thus bypassing a localized lymphatic problem such as the case in an acquired lympedema.2 In the lymph vessel transplantation, a derivation is performed from the lymphatic to the lymphatic system using an autologous lymphatic vessel transplantation.3 Also, the technique of a microsurgical lymphaticovenous anastomosis (end-to-end, end-to-side, or other) is different from the sleeve lymphaticovenous anastomosis, in which one or often more than one lymphatic with its perilymphatic fat is pulled in to a relatively large vein.4 Furthermore, the five lymph node transplantation articles are also compared as being the same, but there are substantial differences in the techniques concerning both the donor and the recipient sites. Cheng et al. described a submental lymph node flap as a donor and the ankle as the recipient in one article.5 In their other article, a groin lymph node flap is transferred to the wrist or elbow.6 Lin et al., Becker et al., and Gharb et al. described the use of groin lymph node flaps but each to a different receptor site (e.g., wrist, axilla).7–9 The physiology of the recipient site might be an important factor in the success of lymph node transplantation, as the pressure in the lymphatic system is different for different receptor sites. For the same reason, labeling and comparing the treatment of lower limb, upper limb, and even genital lymphedema as one group might not be a good idea. The donor site of the lymph nodes also has potentially different complications purely because of its location (e.g., lymphedema of the lower limb in groin node harvest or facial nerve injury in submental node harvest). Although a major concern for many surgeons, until recently, there were no publications of donor-site complications in lymph node transfers. Three recent publications showed that donor-site morbidity can have important implications for the patient and that the procedure should be performed with great caution.10–12 Furthermore, it is evident that a higher complication rate can be expected in free flap surgery such as lymph node transfer (e.g., flap failure, donor-site

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Plastic and Reconstructive Surgery • September 2014 complications) when compared with a lymphaticovenous anastomosis (failure of the anastomosis will not be evident; thus, no revisions). Of course, the absence of a donor site in lymphaticovenous anastomosis is less of a concern. We also think that studies in which patients have benefited from an additional procedure (e.g., liposuction, debulking) to reduce lymphedema because of an unsatisfactory result should be excluded from this meta-analysis. Finally, we think that the conclusions drawn from this meta-analysis should be regarded with great caution, especially for surgeons starting to perform lymphatic surgery. Indications to perform lymph node transfers or lymphaticovenous anastomoses are still not clear, and the potential complications should not be underestimated. Lymph node transfers should be performed by experienced surgeons and with great care. Nevertheless, we congratulate the authors for this analysis and we encourage surgeons performing lymphatic surgery to publish their findings, as much scientific and clinical work has to be done in this exciting field.

7. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123:1265–1275. 8. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315. 9. 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. 10. 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. 11. 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. 12. 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.

DOI: 10.1097/PRS.0000000000000441

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

Assaf A. Zeltzer, M.D. Moustapha Hamdi, M.D., Ph.D. Department of Plastic Surgery University Hospital Brussels Brussels, Belgium Correspondence to Dr. Zeltzer Department of Plastic Surgery University Hospital Brussels Laarbeeklaan 101 Brussels 1090, Belgium [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 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. Capozza L, Negri C. Lympho-venous anastomosis (new surgical technic) (in Italian). Orizz Ortop Odie Riabil. 1966;11: 529–533. 3. Baumeister RG, Seifert J, Hahn D. Autotransplantation of lymphatic vessels. Lancet 1981;17:147. 4. Campisi C, Boccardo F. Microsurgical techniques for lymphedema treatment: Derivative lymphatic-venous microsurgery. World J Surg. 2004;28:609–613. 5. Cheng MH, Huang JJ, Nguyen DH, et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol. 2012;126:93–98. 6. 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.

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Sir:

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

Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplant.

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