LAUSR

Dear Sirs, Post-mastectomy upper extremity lymphedema has been reported to occur in 24–49% of breast cancer patients (Becker et al., 2012). Factors such as congenital absence, extent of axillary surgery, radiation therapy, infection, and trauma can cause lymphatic obstruction or destruction, and subsequent lymphedema development. For patients with postmastectomy lymphedema who desire breast reconstruction, simultaneous deep inferior epigastric perforator (DIEP) flap with groin lymph node transfer (LNT) to the axilla has shown promising results (Nguyen, Chang, Suami, Chang, 2015). Because the groin donor site can cause iatrogenic lymphedema (Vignes, Blanchard, Yannoutsos, & Arrault, 2013), we propose an alternative approach of DIEP flap breast reconstruction with gastroepiploic LNT (GELNT) to treat upper extremity lymphedema following mastectomy. Our technique involves dissecting the DIEP flap(s) in the standard fashion with anastomosis to the internal mammary vessels. Once the abdominal flaps are dissected to the level of the xiphoid process, a 7 cm midline epigastric laparotomy incision is then made. Intraoperatively, gastroepiploic lymph nodes are identified using indocyanine green (ICG) lymphangiography. Starting at the scissura gastrica, dissection is carried along the greater curvature of the stomach to isolate the gastroepiploic vessels. The lymph node flap is then placed into the axilla, forearm, or wrist of the affected extremity (Figure 1). Identification of the lymph nodes using ICG permits division of the flap and bilevel vascularized LNT from single donor site and the distal edge of the lymph node flap is based on the left gastroepiploic vessel. We retrospectively studied five patients who underwent this combination procedure. There were no significant differences in patient demographics or comorbidities. All patients underwent preand postoperative volumetric measurements of the affected upper extremity above and below the elbow and above the wrist. Two patients received bi-level GELNT to the affected axilla and wrist, and three patients underwent single-level transfer. Average volumetric reduction rate was 28.72% at 1 month and 66.34% at 3 months postoperatively. There were no donor site postoperative complications. To our knowledge, two prior studies have described combined autologous breast reconstruction with VLNT from the groin to the axilla for treatment of lymphedema following mastectomy (Nguyen et al., 2015; Saaristo et al., 2012). Our approach differs with use of the gastroepiploic lymph nodes, which seem to have decreased the risk of donor site morbidity. Furthermore, our approach allows for lymph node transfer to the elbow and wrist, in addition to the axilla, potentially resulting in larger reductions in lymphedema. We believe our technique to be an excellent alternative to previously described techniques for the treatment of patients with post-mastectomy upper extremity lymphedema who desire breast reconstruction. Further studies, with a larger sample size, are required to validate its true utility and efficacy.