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.
Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
Identification of the omohyoid muscle laterally and medially facilitates safe identification of the pedicle. Moreover, the transverse cervical artery origin can be variable and the operating surgeon must be mindful of this during dissection. Finally, we have found this flap harvest to be extremely reliable with early success and have not needed to use any dyes to confirm viability. We remain excited that many groups continue to work toward improving our ability to transfer lymph nodes successfully and help patients with this truly potentially devastating condition.
Stamatis Sapountzis, MD Dhruv Singhal, MD Pedro Ciudad, MD Domenico Meo, MD Hung Chi Chen, MD, PhD, FACS Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan [email protected] 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.
Paramuscular Perforators in DIEAP Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature To the Editor: he group from the Hospital de la Santa Creu I Sant Pau in a retrospective review of their multidetector row computed tomography used for preoperative planning for abdominal breast reconstruction over a period of 8 years found a high incidence of a single, dominant so-called paramuscular perforator.1 They have succinctly presented extremely
T
Received November 30, 2014, and accepted for publication, after revision, March 16, 2015 Conflict of interest and sources of funding: none declared. Presented at the 15th International Course on Preforator Flaps, New York, November 22, 2013, and 16th International Course on Perforator Flaps, Ningbo, China, November 9, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0745 DOI: 10.1097/SAP.0000000000000535
FIGURE 1. Modified from Nakajima et al2 Figure 2, showing their “six patterns of the vascular supply to the fasciocutaneous plexus.” The dotted circle encompasses the vascular pedicle at the hilum of a muscle, where their type “C” branch arises from that muscle source vessel just before the latter enters the muscle. Note that type “C” is their “direct cutaneous branch of muscular vessel,” or more simply today, a “paramuscular” perforator.
valuable data for anyone performing DIEAP flap surgery, noting that this perforator courses around the medial border of the rectus abdominis muscle after arising from the medial branch of the deep inferior epigastric vessels, with a total retromuscular course. It ultimately pierces the anterior rectus sheath lateral to the linea alba and eventually reaches the subdermal plexus. Muscle function will always be totally preserved because there is no need for any muscle dissection, and the more laterally located motor nerves are always avoided. As would be anticipated, flap harvest time should thereby also be expedited to make this usually large caliber perforator a more efficient choice. An historical overview of the evolution of this important topic is thus warranted. Interestingly, Nakajima et al2 predicted in this journal as early as 1986 the existence of what they called a “direct cutaneous branch of muscular vessel.” Exiting from the hilum of the source vessel to a muscle just before the latter entering that muscle (Fig. 1), these branches course around that same muscle to then pierce the deep fascia and continue onto the skin. Vandevoort et al3 called them “paramedian” perforators in their review of the topography of DIEAP flaps that were to be used for breast reconstruction. Chen and Allen,4 and the Group for the Advancement of Breast Reconstruction,5 instead applied the appellation “septocutaneous” perforator following the suggestion of the Gent nomenclature that perforator flaps must be direct perforator flaps, muscle perforator flaps, or septal perforator flaps.6 Presumably, for the same reason, the Barcelona group concluded that their “paramuscular perforator can be considered a septal perforator because it traverses the intermuscular septum only to supply the overlying tissue.1”
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Yet remembering our common introduction to basic anatomy, an intermuscular septum was defined as a “lamina of deep fascia which extends between and encloses muscle groups.7” One must also acknowledge that the sheath surrounding the rectus abdominis muscle is formed by the fusion and/or separation of the aponeuroses of the internal and external abdominal oblique muscles and transversus abdominis muscle.8 An aponeuroses is a sheet-like tendon and not a septum at all.9 Therefore, these “paramuscular” perforators are neither septal nor muscular perforators as they do not pass through a “true” septum nor muscle,10 and as Nakajima et al2 had postulated would represent a fourth important type of perforator flap that requires its own unique approach to perforator identification and surgical dissection. Gravvanis et al11 made an important contribution in regard to this terminology. Indeed, these are paramuscular perforators, supplying paramuscular perforator flaps, and should be called such.
Geoffrey G. Hallock, MD Division of Plastic Surgery Sacred Heart and Lehigh Valley Hospitals Allentown, Pennsylvania St. Luke's Hospital Bethlehem, PA [email protected]
REFERENCES 1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
745
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.
Annals of Plastic Surgery • Volume 74, Number 6, June 2015
Letter to the Editor
Identification of the omohyoid muscle laterally and medially facilitates safe identification of the pedicle. Moreover, the transverse cervical artery origin can be variable and the operating surgeon must be mindful of this during dissection. Finally, we have found this flap harvest to be extremely reliable with early success and have not needed to use any dyes to confirm viability. We remain excited that many groups continue to work toward improving our ability to transfer lymph nodes successfully and help patients with this truly potentially devastating condition.
Stamatis Sapountzis, MD Dhruv Singhal, MD Pedro Ciudad, MD Domenico Meo, MD Hung Chi Chen, MD, PhD, FACS Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan [email protected] 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.
Paramuscular Perforators in DIEAP Flap for Breast Reconstruction An Important Variation in Perforator Flap Nomenclature To the Editor: he group from the Hospital de la Santa Creu I Sant Pau in a retrospective review of their multidetector row computed tomography used for preoperative planning for abdominal breast reconstruction over a period of 8 years found a high incidence of a single, dominant so-called paramuscular perforator.1 They have succinctly presented extremely
T
Received November 30, 2014, and accepted for publication, after revision, March 16, 2015 Conflict of interest and sources of funding: none declared. Presented at the 15th International Course on Preforator Flaps, New York, November 22, 2013, and 16th International Course on Perforator Flaps, Ningbo, China, November 9, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0745 DOI: 10.1097/SAP.0000000000000535
FIGURE 1. Modified from Nakajima et al2 Figure 2, showing their “six patterns of the vascular supply to the fasciocutaneous plexus.” The dotted circle encompasses the vascular pedicle at the hilum of a muscle, where their type “C” branch arises from that muscle source vessel just before the latter enters the muscle. Note that type “C” is their “direct cutaneous branch of muscular vessel,” or more simply today, a “paramuscular” perforator.
valuable data for anyone performing DIEAP flap surgery, noting that this perforator courses around the medial border of the rectus abdominis muscle after arising from the medial branch of the deep inferior epigastric vessels, with a total retromuscular course. It ultimately pierces the anterior rectus sheath lateral to the linea alba and eventually reaches the subdermal plexus. Muscle function will always be totally preserved because there is no need for any muscle dissection, and the more laterally located motor nerves are always avoided. As would be anticipated, flap harvest time should thereby also be expedited to make this usually large caliber perforator a more efficient choice. An historical overview of the evolution of this important topic is thus warranted. Interestingly, Nakajima et al2 predicted in this journal as early as 1986 the existence of what they called a “direct cutaneous branch of muscular vessel.” Exiting from the hilum of the source vessel to a muscle just before the latter entering that muscle (Fig. 1), these branches course around that same muscle to then pierce the deep fascia and continue onto the skin. Vandevoort et al3 called them “paramedian” perforators in their review of the topography of DIEAP flaps that were to be used for breast reconstruction. Chen and Allen,4 and the Group for the Advancement of Breast Reconstruction,5 instead applied the appellation “septocutaneous” perforator following the suggestion of the Gent nomenclature that perforator flaps must be direct perforator flaps, muscle perforator flaps, or septal perforator flaps.6 Presumably, for the same reason, the Barcelona group concluded that their “paramuscular perforator can be considered a septal perforator because it traverses the intermuscular septum only to supply the overlying tissue.1”
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Yet remembering our common introduction to basic anatomy, an intermuscular septum was defined as a “lamina of deep fascia which extends between and encloses muscle groups.7” One must also acknowledge that the sheath surrounding the rectus abdominis muscle is formed by the fusion and/or separation of the aponeuroses of the internal and external abdominal oblique muscles and transversus abdominis muscle.8 An aponeuroses is a sheet-like tendon and not a septum at all.9 Therefore, these “paramuscular” perforators are neither septal nor muscular perforators as they do not pass through a “true” septum nor muscle,10 and as Nakajima et al2 had postulated would represent a fourth important type of perforator flap that requires its own unique approach to perforator identification and surgical dissection. Gravvanis et al11 made an important contribution in regard to this terminology. Indeed, these are paramuscular perforators, supplying paramuscular perforator flaps, and should be called such.
Geoffrey G. Hallock, MD Division of Plastic Surgery Sacred Heart and Lehigh Valley Hospitals Allentown, Pennsylvania St. Luke's Hospital Bethlehem, PA [email protected]
REFERENCES 1. Pons G, Masia J, Sanchez-Porro L, et al. Paramuscular perforators in DIEAP flap for breast reconstruction. Ann Plast Surg. 2014;73:659–661. 2. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
745
