Letter: Tips for Treatment and Following Secondary Upper Extremity Lymphedema

Dear Editor:

We read the article “Efficacy of Lymphaticovenular Anastomosis for Secondary Upper Extremity Lymphedema: Treatment Strategies with Effects of Compression Therapy Discontinuation and Site-Specific Evaluation of the Upper Extremity” by Hamada et al. (Lymphat Res Biol. 2023 May 26). ¹ We agree with the importance of site-specific evaluation of extremity lymphedema, especially around the elbow or the knee, where the joint’s movement can be affected.

Based on our experiences, elbow lymphedema tends to persist longer compared with other sites in the upper extremity. To improve lymphedema around the elbow, it is important to perform lymphaticovenular anastomosis not only in the main medial lymphosome but also in the minor lymphosomes by evaluating with indocyanine green (ICG) lymphography.^2,3 Other concerns include the evaluation method and shorter follow-up period. Circumference measurement, the most commonly applied lymphedema volume evaluation, is not optimal for site-specific evaluation, as it allows only one-dimensional evaluation, whereas lymphedematous volume change is three-dimensional.^4,5 To appropriately evaluate site-specific volume changes, three-dimensional volumetry or body-type corrected ones should be applied. Although the authors reported eight patients who could be free from compression, the postoperative follow-up was only 6 months, and there would be a significant re-progression risk in a longer follow-up. To confirm improved circulation, it is critical to assess postoperative lymph circulation with highly sensitive lymphography, such as ICG lymphography. Only when a patient shows volume reduction, no cellulitis, no sensation of tension, and improved lymph circulation, compression should be reduced gradually and finally relieved.

We hope that patients with lymphedema are followed and managed appropriately after lymphedema surgery.