Optimizing Quality of Life for Patients with Breast Cancer–Related Lymphedema: A Prospective Study Combining DIEP Flap Breast Reconstruction and Lymphedema Surgery

Sir: We read with interest the article by Chang et al.1 on combining deep inferior epigastric perforator (DIEP) flap breast reconstruction and lymphedema surgery for optimizing quality of life for patients with breast cancer–related lymphedema. We would like to congratulate them on their sublime results achieved with the breast reconstruction including lymphovenous anastomosis and inguinal-to-axillary node transfer (BRILIANT) technique, coupling autologous breast reconstruction and vascularized inguinal-to-axillary lymph node transfer with lymphovenous anastomosis. We concur that the combined approach of lymphovenous anastomosis shunts and inguinal-to-axillary node transfer during DIEP flap is a promising and effective approach for reducing breast cancer–related lymphedema. Over the past 5 years, we have successfully performed 56 DIEP procedures with lymph node transfers where in four cases an additional lymphovenous anastomosis procedure was performed (data not published). In this study, all patients underwent single-photon emission computed tomography preoperatively. Intraoperatively, reverse lymph node mapping was used to spare sentinel nodes, and lymph nodes included in the flap were estimated on palpation. In our practice, all patients undergo computed tomographic angiography preoperatively. This scan is modeled into a three-dimensional virtual scan of the blood vessels and inguinal lymph nodes that is projected on the patient’s abdomen before surgery.2 Intraoperatively, lymph nodes in the flap are located by markings on the skin, which we confirm by palpation. We believe that the three-dimensional virtual support method is preferable to single-photon emission computed tomography, as precise intraoperative guidance results in a more accurate representation of lymph node inclusion and the radiation dose is lower. In this study by Change et al., the authors were unable to prove a significant volumetric difference after 12 months. In the discussion of the article, the authors suggest that postoperative indocyanine green lymphatic mapping would be helpful for assessing the longevity of the lymphovenous anastomosis and to determine the contribution of the shunts to the final outcome. We agree with the authors that postoperative follow-up with indocyanine green lymphography would have been a valuable addition to the article to quantify the improvement of lymphedema. However, although indocyanine green has proven to be an excellent diagnostic tool to evaluate the functionality of lymph vessels and to evaluate improvement of the lymphatic drainage after lymphatic surgery, we deem the role of indocyanine green in determining patency of lymphovenous anastomosis shunts to be unsure.3 We recently published a retrospective study on the patency of lymphovenous anastomosis shunts in upper extremities using indocyanine green lymphography in which we have shown that at least 56.5 percent of the shunts were patent after 12 months.3 Volumetric difference reduction was observed in 11 of 12 patients; however, in four patients, we were not able to visualize the lymphovenous anastomosis. Therefore, we tread cautiously during the interpretation of long-term indocyanine green lymphography for determining shunt patency alone. We do believe that it is valuable to incorporate indocyanine green lymphography in the postoperative follow-up of lymphatic surgery, following a replicable protocol to assess lymphatic drainage by observing dermal backflow patterns. However, we do not rely solely on this technique to quantify the patency of the anastomosis. Questionnaires, volumetric assessment, and clinical examination are equally important. DISCLOSURE The authors have no commercial associations or financial disclosures to declare in relation to the content of this communication. Laura C. Burlage, M.D., Ph.D.Harm Winters, M.D.Hanneke J. P. Tielemans, M.D.Stefan Hummelink, Ph.D.Dietmar J. O. Ulrich, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryRadboud University Medical CenterNijmegen, The Netherlands