Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
flap, with an earlier return to load capacity and a full recovery to normal activity. We thank the authors for coming up with such meaningful questions. The operative method showed in the article mostly is our clinical experience. And just as the protective sensation appeared in the flaps without nerve repair, another interesting phenomenon in clinical work is also discovered in our hospital. Although the nerve pierces the harvesting flap and does not mainly supply the dermatome of the flap, nerve coaptation with the local nerve in recipient sites can significantly accelerate the protective sensibility recovering. The reason needs exploring and more certain clinical conclusion must be based on other supporting evidence, including anatomical and/or physiological research.
Yu Zhou, MM Liaoning Medical College Jinzhou, China
preliminary surgical results and their detailed anatomical description. However, it seems that the introduction, “In our review of the literature, no prior description of harvesting cervical lymph nodes as a donor site for lymph node transfer in lymphedema was found,” is inappropriate. As in the early 2013, Althubaiti et al2 first published an article describing a lymph node flap based on the transverse cervical artery, which they called “vascularized supraclavicular lymph node.” Besides, a flap in the “supraclavicular fossa” had been mentioned in Becker et al3 in 2012 and Sapountzis et al4 in 2013. Both of their studies have described lymph node flaps based on the transverse cervical artery. The issue about lymph node flap is encouraging. Nevertheless, we still have a long way to go before winning the battle against lymphedema.
Lifeng Liu, MD Xuecheng Cao, MD Jinfang Cai, MD
Sze Yuan Chou, MD Department of Surgery Cheng Ching General Hospital Taichung, Taiwan
Orthopedic Department General Hospital of Jinan Military Command Jinan, China [email protected]
Ching-Yueh Wei, MD Department of Plastic and Reconstructive Surgery Cheng Ching General Hospital Taichung, Taiwan [email protected]
REFERENCES 1. Phillips LH, Park TS. Electrophysiological mapping of the segmental innervation of the saphenous and sural nerves. Muscle Nerve. 1993;16:827–831. 2. Riedl O, Frey M. Anatomy of the sural nerve: cadaver study and literature review. Plast Reconstr Surg. 2013;131:802–810. 3. Santanelli F, Tenna S, Pace A, et al. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg. 2002; 109:2314–2322. 4. Kuran I, Turgut G, Bas L, et al. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg. 2000;105:574–580.
Lymph Node Flap Based on the Right Transverse Cervical Artery as a Donor Site for Lymph Node Transfer
ACKNOWLEDGMENT The authors thank Nathan Wei for the assistance in editing this article. REFERENCES 1. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2014;73:398–401. 2. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131:133e–135e. 3. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39:385–398. 4. Sapountzis S, Nicoli F, Chilgar R, et al. Evidencebased analysis of lymph node transfer in postmastectomy upper extremity lymphedema. Arch Plast Surg. 2013;40:450–451.
To the Editor: e read with great interest the article by Sapountzis et al1 entitled “Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer.” We congratulate the authors on their good
Lymph Node Flap Based on the Right Transverse Cervical Artery as a Donor Site for Lymph Node Transfer: Reply
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043-/15/7406-0744 DOI: 10.1097/SAP.0000000000000405
Dear Editor, e would like to thank the authors for their interest in our study. Regarding the first comment, we would like to note that our study1 was submitted to
W
744
www.annalsplasticsurgery.com
W
the Annals of Plastic Surgery on September 29, 2012, and accepted in November of 2012, before the publication of the viewpoint of Althubaiti et al2 in the January 2013 edition of Plastic and Reconstructive Surgery and we sincerely had no knowledge of their work or manuscript at the time of our submission and acceptance to the Annals of Plastic Surgery. Furthermore, Althubaiti et al in their article claim “…this is the first report of using supraclavicular flap as a vascularized lymph node transfer…” without citing the 2012 article of Becker et al.3 Although we apologize for the oversight in not citing the article of Becker et al as well, we would like to note that in their article, no description of the flap harvest, anatomical landmarks, variation in anatomy, donor-site morbidity, and advantages/disadvantages of this flap was provided. We would like to emphasize that Dr Becker's role as the founding figure of lymph node transplantation remains indisputable. As commonly occurs in academic medicine, many groups will stumble upon similar discoveries over similar time courses and overlapping manuscripts will cross themselves to publication. Omissions such as ours are regrettable but we also believe, unavoidable. Perhaps most importantly, this does provide us with an opportunity to highlight some important differences between our descriptions of the supraclavicular lymph node transfer. Most of the description provided by Althubaiti et al on the supraclavicular lymph node transfer focuses on preserving a skin island over the supraclavicular flap. No actual description of the lymph node harvest is provided. The authors do mention the role of indocyanine green dye to confirm the vascularity of the lymph nodes. In our study of 11 patients, we do not routinely preserve a skin island. In our experience, the skin island can be unreliable and therefore our initial incision most often proceeds directly to a subplatysmal dissection and the donor incision is closed primarily. We would like to emphasize precise anatomical landmarks that are critical for lymph node harvest and success. Namely, the supraclavicular lymph node flap has 2 potential venous outflow systems via the transverse cervical vein and the external jugular vein. We routinely include both systems in our harvest. Received November 13, 2014, and accepted for publication, after revision, November 14, 2014. From the Department of Plastic and Reconstructive Surgery, China Medical University Hospital Taichung, Taiwan
Conflicts of interest and sources of funding: none declared. Reprints: Stamatis Sapountzis, MD, Department of Plastic Surgery, China Medical University Hospital/China Medical University, 2, Yuh-der Rd, Taichung, Taiwan. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0744 DOI: 10.1097/SAP.0000000000000422
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letter to the Editor
flap, with an earlier return to load capacity and a full recovery to normal activity. We thank the authors for coming up with such meaningful questions. The operative method showed in the article mostly is our clinical experience. And just as the protective sensation appeared in the flaps without nerve repair, another interesting phenomenon in clinical work is also discovered in our hospital. Although the nerve pierces the harvesting flap and does not mainly supply the dermatome of the flap, nerve coaptation with the local nerve in recipient sites can significantly accelerate the protective sensibility recovering. The reason needs exploring and more certain clinical conclusion must be based on other supporting evidence, including anatomical and/or physiological research.
Yu Zhou, MM Liaoning Medical College Jinzhou, China
preliminary surgical results and their detailed anatomical description. However, it seems that the introduction, “In our review of the literature, no prior description of harvesting cervical lymph nodes as a donor site for lymph node transfer in lymphedema was found,” is inappropriate. As in the early 2013, Althubaiti et al2 first published an article describing a lymph node flap based on the transverse cervical artery, which they called “vascularized supraclavicular lymph node.” Besides, a flap in the “supraclavicular fossa” had been mentioned in Becker et al3 in 2012 and Sapountzis et al4 in 2013. Both of their studies have described lymph node flaps based on the transverse cervical artery. The issue about lymph node flap is encouraging. Nevertheless, we still have a long way to go before winning the battle against lymphedema.
Lifeng Liu, MD Xuecheng Cao, MD Jinfang Cai, MD
Sze Yuan Chou, MD Department of Surgery Cheng Ching General Hospital Taichung, Taiwan
Orthopedic Department General Hospital of Jinan Military Command Jinan, China [email protected]
Ching-Yueh Wei, MD Department of Plastic and Reconstructive Surgery Cheng Ching General Hospital Taichung, Taiwan [email protected]
REFERENCES 1. Phillips LH, Park TS. Electrophysiological mapping of the segmental innervation of the saphenous and sural nerves. Muscle Nerve. 1993;16:827–831. 2. Riedl O, Frey M. Anatomy of the sural nerve: cadaver study and literature review. Plast Reconstr Surg. 2013;131:802–810. 3. Santanelli F, Tenna S, Pace A, et al. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg. 2002; 109:2314–2322. 4. Kuran I, Turgut G, Bas L, et al. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg. 2000;105:574–580.
Lymph Node Flap Based on the Right Transverse Cervical Artery as a Donor Site for Lymph Node Transfer
ACKNOWLEDGMENT The authors thank Nathan Wei for the assistance in editing this article. REFERENCES 1. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2014;73:398–401. 2. Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131:133e–135e. 3. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39:385–398. 4. Sapountzis S, Nicoli F, Chilgar R, et al. Evidencebased analysis of lymph node transfer in postmastectomy upper extremity lymphedema. Arch Plast Surg. 2013;40:450–451.
To the Editor: e read with great interest the article by Sapountzis et al1 entitled “Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer.” We congratulate the authors on their good
Lymph Node Flap Based on the Right Transverse Cervical Artery as a Donor Site for Lymph Node Transfer: Reply
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043-/15/7406-0744 DOI: 10.1097/SAP.0000000000000405
Dear Editor, e would like to thank the authors for their interest in our study. Regarding the first comment, we would like to note that our study1 was submitted to
W
744
www.annalsplasticsurgery.com
W
the Annals of Plastic Surgery on September 29, 2012, and accepted in November of 2012, before the publication of the viewpoint of Althubaiti et al2 in the January 2013 edition of Plastic and Reconstructive Surgery and we sincerely had no knowledge of their work or manuscript at the time of our submission and acceptance to the Annals of Plastic Surgery. Furthermore, Althubaiti et al in their article claim “…this is the first report of using supraclavicular flap as a vascularized lymph node transfer…” without citing the 2012 article of Becker et al.3 Although we apologize for the oversight in not citing the article of Becker et al as well, we would like to note that in their article, no description of the flap harvest, anatomical landmarks, variation in anatomy, donor-site morbidity, and advantages/disadvantages of this flap was provided. We would like to emphasize that Dr Becker's role as the founding figure of lymph node transplantation remains indisputable. As commonly occurs in academic medicine, many groups will stumble upon similar discoveries over similar time courses and overlapping manuscripts will cross themselves to publication. Omissions such as ours are regrettable but we also believe, unavoidable. Perhaps most importantly, this does provide us with an opportunity to highlight some important differences between our descriptions of the supraclavicular lymph node transfer. Most of the description provided by Althubaiti et al on the supraclavicular lymph node transfer focuses on preserving a skin island over the supraclavicular flap. No actual description of the lymph node harvest is provided. The authors do mention the role of indocyanine green dye to confirm the vascularity of the lymph nodes. In our study of 11 patients, we do not routinely preserve a skin island. In our experience, the skin island can be unreliable and therefore our initial incision most often proceeds directly to a subplatysmal dissection and the donor incision is closed primarily. We would like to emphasize precise anatomical landmarks that are critical for lymph node harvest and success. Namely, the supraclavicular lymph node flap has 2 potential venous outflow systems via the transverse cervical vein and the external jugular vein. We routinely include both systems in our harvest. Received November 13, 2014, and accepted for publication, after revision, November 14, 2014. From the Department of Plastic and Reconstructive Surgery, China Medical University Hospital Taichung, Taiwan
Conflicts of interest and sources of funding: none declared. Reprints: Stamatis Sapountzis, MD, Department of Plastic Surgery, China Medical University Hospital/China Medical University, 2, Yuh-der Rd, Taichung, Taiwan. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0744 DOI: 10.1097/SAP.0000000000000422
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
