Letter to the Editor Response to: Comparisons of Submental and Groin Vascularized Lymph Node Flaps Transfer for Breast Cancer–related Lymphedema Usama Abdelfattah, MD*†; Jaume Masià, MD, PhD* Sir, Third, the authors stated that the VGLN is considered M icrosurgical treatment of lymphedema has been one of our major activities for more than 14 years. Therefore, while reviewing the literature, we were pleased more bulky than the VSLN, and so the cosmetic result is much better with the VSLN patients; this is clarified in Figure 1, with the marking of VGLN flap seen below to read a recently published article by Ming-Huei Cheng the inguinal crease. VGLN flap has been described in demonstrating a comparison between 2 lymph node flaps the literature,6,7 and according to our experience, the in the management of upper extremity lymphedema.1 sub-Scarpa’s lymph nodes located between the inguinal The authors compared the results of groin (vascular- ligament and inguinal crease are the draining lymph ized groin lymph node [VGLN]) and submental (vascu- nodes of the lower abdomen and hence targeted for larized submental lymph node [VSLN]) flaps in breast VGLN transfer. Usually, the VGLN is the superficial flap cancer related lymphedema in terms of flap characteris- located within the territory of the superficial circum- tics, operative time, perioperative complications, and limb flex iliac pedicle. This anatomical description is criti- circumference changes at follow-up. We would like to dis- cal as going below the inguinal crease has 2 drawbacks: cuss some conclusions for which we do not agree with the first, it could raise the risk of donor-site lymphedema authors. particularly if the authors do not use reverse lymphatic First, in their article, the authors did not mention mapping; second, the skin quality of the flap below the the stage of lymphedema of the patients in both groups; inguinal crease is not ideal and could give a poor cos- instead, they mentioned the duration of symptoms, as we metic outcome in terms of the donor-site scar in upper know the lymphedema patients are diagnosed accord- thigh and unpleasant bulkiness at the recipient site, as ing to standard criteria based on history, clinical exami- the authors reported. nation, and a variety of radiological studies, including Finally, the authors found that the donor vein in the lymphoscintigraphy, magnetic resonance lymphangi- VSLN flap is relatively larger than that of the VGLN flap, ography, or indocyanine green lymphogrphy, which all which is probably responsible for the higher total periop- collaborated to a standard stage.2 Whatever the staging erative complications associated with the VGLN transfer; system used (eg, International Society of Lymphology), it however, it is obvious that the study lacks proper matching is important to classify the degree of lymphedema, which of the perioperative risk of complications and the salvage is critical in guiding decision-making, as well as in deter- procedures between the 2 groups of patients. Moreover, mination of the prognosis and response to reconstructive the VGLN flap has the advantage of having the superfi- interventions.3,4 cial inferior epigastric vein or the superficial circumflex Second, in the interpretation of results, the authors Iliac vein or both to be included in the flap, with suffi- found that donor-site lymphedema was statistically signifi- cient length up to 6–7 cm when the skin paddle is properly cantly higher in the VGLN flap group than in the VSLN designed. group (7.7% versus 0%; P = 0.04). However, we all know Nevertheless, we congratulate the authors for their that the donor-site lymphedema following VGLN harvest great efforts. However, we need better and well-controlled is significantly minimized with reverse lymphatic map- data in lymphedema management with objective standard ping, which is now considered mandatory for all patients evaluation. subjected to that surgery.5 Jaume Masià, MD, PhD Plastic Surgery Department From the *Department of Plastic and Reconstructive Surgery, Hospital de la Santa Creu i Sant Pau Hospital de la Santa Creu I Sant Pau, School of Medicine at School of Medicine at Universitat Autònoma de Barcelona Sant Quintí, 89 Universitat Autònoma, Barcelona, Spain; and †Plastic and 08041 Barcelona Reconstructive Surgery Department, Al-Azhar University, Cairo, E-mail: Jmasia@santpau.cat Egypt. Copyright © 2020 The Authors. Published by Wolters Kluwer Health, DISCLOSURE Inc. on behalf of The American Society of Plastic Surgeons. This The authors have no financial interest to declare in relation to is an open-access article distributed under the terms of the Creative the content of this article. Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the REFERENCES work provided it is properly cited. The work cannot be changed in 1. Ho OA, Lin CY, Pappalardo M, et al. Comparisons of submen- any way or used commercially without permission from the journal. tal and groin vascularized lymph node flaps transfer for breast Plast Reconstr Surg Glob Open 2020;8:e2749; doi: 10.1097/ cancer-related lymphedema. Plast Reconstr Surg Glob Open. 2018;6: GOX.0000000000002749; Published online 22 September 2020.) e1923. www.PRSGlobalOpen.com 1 PRS Global Open • 2020 2. International Society of Lymphology. The diagnosis and treatment 5. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a of peripheral lymphedema: 2013 consensus document of the new technique for maximizing safety in vascularized lymph node International Society of Lymphology. Lymphology. 2013;46:1–11. transfer. Plast Reconstr Surg. 2015;135:277–285. 3. Garza R, Skoracki R, Hock K, et al. A comprehensive overview 6. Dayan JH, Dayan E, Kagen A, et al. The use of magnetic reso- on the surgical management of secondary lymphedema of the nance angiography in vascularized groin lymph node transfer: upper and lower extremities related to prior oncologic thera- an anatomic study. J Reconstr Microsurg. 2014;30:41–46. pies. BMC Cancer. 2017;17:468. 7. Gharb BB, Rampazzo A, di Spilimbergo SS, et al. Vascularized lymph 4. Chang DW, Masia J, Garza R III, et al. Lymphedema: surgical and node transfer based on the hilar perforators improves the outcome medical therapy. Plast Reconstr Surg. 2016;138(3S):209S–218S. in upper limb lymphedema. Ann Plast Surg. 2011;67:589–593. 2