Cordova, Adriana

Costa, Renato

D'Arpa, Salvatore

Moschella, Francesco

Rossi, Matteo

Ghent University Academic Bibliography

Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 240ePlastic and Reconstructive Surgery • July 2017Correspondence to Dr. AkitaDepartment of Plastic, Reconstructive, and Aesthetic SurgeryChiba University Graduate School of Medicine1-8-1, Inohana, Chuo-kuChiba City, Chiba 260-8670, JapandisclosureThe authors have no financial interest to declare in rela-tion to the content of this communication.Fig. 1. In a patient with adult-onset primary upper extremity lymphedema, bilateral lymphatic function is usually very different.Fig. 2. When the collateral route develops, the accumulation of dye at lymph nodes may not be indicative of lymphatic function.reply: comparison of Preoperative and Postoperative lymphatic Function is  essential to understand the changes in lymphatic FunctionSir:We have read Dr. Akita and Dr. Mitsukawa’s com-ment with interest and we agree with many of their statements regarding the usefulness of lymphoscin-tigraphy and indocyanine green lymphography in the diagnosis of limb lymphedema.1 As a comment to their letter, we would like to further discuss the importance that the two methods have in the prevention, diagnosis, and treatment of secondary upper limb lymphedema after axillary dissection.reFerences 1. Rossi M, Grassi R, Costa R, et al. Evaluation of the upper limb lymphatic system: A prospective lymphoscintigraphic study in melanoma patients and healthy controls. Plast Reconstr Surg. 2016;138:1321–1331. 2. Silva AK, Chang DW. Discussion: Evaluation of the upper limb lymphatic system: A prospective lymphoscintigraphic study in melanoma patients and healthy controls. Plast Recon-str Surg. 2016;138:1332. 3. Akita S, Mitsukawa N, Kazama T, et al. Comparison of lym-phoscintigraphy and indocyanine green lymphography for the diagnosis of extremity lymphoedema. J Plast Reconstr Aes-thet Surg. 2013;66:792–798. 4. Akita S, Nakamura R, Yamamoto N, et al. Early detection of lymphatic disorder and treatment for lymphedema following breast cancer. Plast Reconstr Surg. 2016;138: 192e–202e.Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 140, Number 1 • Letters241eLymphoscintigraphy provides a complete picture of lymphatic flow in both upper limbs, allowing us to simultaneously visualize, in anterior and posterior projections, their lymphatic structures (vessels and nodes), and to observe the liver uptake of the radio-tracer as an expression of lymph progression from the injection site to the systemic venous circulation.2 After an axillary dissection, absent visualization of infraclavicular/supraclavicular nodes and the pres-ence of dermal backflow are lymphoscintigraphic cri-teria for lymphedema (Fig. 1).3 As Dr. Akita correctly pointed out, accumulation of the radiotracer in the axillary nodes may not necessarily indicate lymphatic function.1 Theoretically, regardless of the explanation provided by Akita, after axillary dissection, axillary nodes should not be visualized. Accumulation in axil-lary nodes in the presence of dermal backflow could indicate residual lymphatic function but also incom-plete dissection: in these contexts, the presence of residual axillary nodes with related lymphatics does not guarantee a normal lymphatic flow. As a result, lymphedema develops because no compensation, such as the formation of lymphaticovenous anastomo-ses, develops (Fig. 2).Asymmetry and delayed tracer appearance time do not necessarily indicate lymphatic dysfunction, because they are present even preoperatively and in healthy individuals.2 However, as we suggested and as Akita confirmed, preoperative and postoperative lympho-scintigraphic patterns based on tracer appearance time Fig. 1. Anterior projection (ANT) of lymphoscintigraphic image taken at 120 minutes after injection of the radiotracer in the sec-ond interdigital webspace of both hands in a female breast can-cer patient after axillary lymphadenectomy with right (R) upper limb lymphedema. Lymphoscintigraphy shows absent visualiza-tion of infraclavicular/supraclavicular lymph nodes (red arrow) and dermal backflow (green arrow) on the right upper limb. L, left.should be investigated in future studies because they could allow detection of predisposed individuals.1,2,4Indocyanine green lymphography, compared with lymphoscintigraphy, allows early diagnosis of lymph-edema without radiation exposure and provides detailed anatomical information on superficial lymphatic vessels and on the distribution of lymphatic alterations in a lymphedematous limb. It also allows accurate surgical planning by identifying patients who have residual lym-phatic function and localization of those lymphatics for lymphaticovenous anastomoses.4,5 Its limit is that it does not allow simultaneous visualization of both limbs, to analyze deeper lymphatic structures and the relation-ships between the deep and superficial lymphatic sys-tems and the systemic venous circulation.1,2Lymphoscintigraphy and indocyanine green lym-phography do not exclude each other but are rather complementary. They should both be used preopera-tively and postoperatively in patients at risk for and in patients affected by lymphedema. To do this would allow us to better understand the physiology of a nor-mal lymphatic system (preoperatively) and the patho-logic and/or compensation mechanisms that begin after a traumatic event such as surgery for lymph node dissection. The combination of both allows better treat-ment planning by combining the detailed anatomical and functional information of indocyanine green lym-phography with the functional overview on lymphatic flow provided by lymphoscintigraphy. We still do not Fig. 2. Anterior projection (ANT) of lymphoscintigraphic image taken at 120 minutes after injection of the radiotracer in the sec-ond interdigital webspace of both hands in a female breast can-cer patient after axillary lymphadenectomy with left (L) upper limb lymphedema. Lymphoscintigraphy shows visualization of residual axillary nodes (blue arrow), infraclavicular/supraclavicu-lar lymph nodes (red arrow), and dermal backflow (green arrow) on the left upper limb. R, right.Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 242ePlastic and Reconstructive Surgery • July 2017know enough about lymphedema and lymphatic func-tion to declare that one technique is better than the other: all our weapons should be used to provide detailed information.DOI: 10.1097/PRS.0000000000003464Matteo rossi, M.d., Ph.d.Plastic and Reconstructive SurgeryDepartment of Surgical, Oncological, and Oral SciencesUniversity of PalermoPalermo, Italysalvatore d’Arpa, M.d., Ph.d.Department of Plastic and Reconstructive SurgeryGhent University HospitalGhent, Belgiumrenato costa, M.d.Nuclear MedicineBiomedical Department of Internal and Specialist MedicineUniversity of PalermoPalermo, ItalyFrancesco Moschella, M.d.Plastic and Reconstructive SurgeryDepartment of Surgical, Oncological, and Oral SciencesUniversity of PalermoPalermo, ItalyAdriana cordova, M.d.Plastic and Reconstructive SurgeryDepartment of Surgical, Oncological, and Oral SciencesUniversity of PalermoPalermo, ItalyCorrespondence to Dr. Matteo RossiPlastic and Reconstructive SurgeryDepartment of Surgical, Oncological, and Oral SciencesUniversity of PalermoVia del Vespro 12990127 Palermo, Italymatt.rossi17@virgilio.itdisclosureThe authors have no financial interest to declare in rela-tion to the content of this communication.reFerences 1. Akita S, Mitsukawa N. Comparison of preoperative and post-operative lymphatic function is essential to understand the changes in lymphatic function (Letter). Plast Reconstr Surg. 2017;140:239e–240e. 2. Rossi M, Grassi R, Costa R, et al. Evaluation of the upper limb lymphatic system: A prospective lymphoscintigraphic study in melanoma patients and healthy controls. Plast Reconstr Surg. 2016;138:1321–1331. 3. Mikami T, Hosono M, Yabuki Y, et al. Classification of lym-phoscintigraphy and relevance to surgical indication for lymphaticovenous anastomosis in upper limb lymphedema. Lymphology 2011;44:155–167. 4. Rossi M, D’Arpa S, Costa R, Moschella F, Cordova A. Reply: Time to re-consider a gold standard of lymph flow imaging: Importance of reliability to detect abnormal lymphodynam-ics in lymphedema screening after cancer treatments. Plast Reconstr Surg. 2017;139:1029e–1030e. 5. Masià J, Pons G, Rodríguez-Bauzà E. Barcelona lymphedema algorithm for surgical treatment in breast cancer-related lymphedema. J Reconstr Microsurg. 2016;32:329–335.

Reply: Comparison of preoperative and postoperative lymphatic function is essential to understand the changes in lymphatic function

Matteo Rossi

Salvatore D’Arpa

Renato Costa

Francesco Moschella

Adriana Cordova

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Reply: Comparison of Preoperative and Postoperative Lymphatic Function is Essential to Understand the Changes in Lymphatic Function

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Reply: Comparison of preoperative and postoperative lymphatic function is essential to understand the changes in lymphatic function

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