Sir:FigureWe would like to thank Dr. Corrado Campisi and colleagues for their comments regarding our article entitled “Immediate Breast Reconstruction and Lymphedema Incidence.”1 The authors present a relevant discussion concerning the prevention of lymphatic injuries in breast cancer patients by using microsurgical techniques. By identifying lymphatic disruption at the time of axillary node dissection and performing lymphaticovenous anastomoses between afferent lymphatics and collateral branches of the axillary vein, this technique may allow bypass of injured lymphatics and potential prevention of breast cancer–related lymphedema. The authors report on their recently published prospective randomized study comparing the lymphatic microsurgical preventive healing approach (lymphaticovenous anastomoses) to no intervention in consecutive women undergoing complete axillary dissection.2 A significant difference in lymphedema incidence was found between groups with a follow-up of 18 months. The authors found no difference in age, body mass index, positive lymph nodes, number of lymph nodes removed, radiotherapy, and incidence of cellulitis between the two cohorts. Postoperative compression therapy was not performed in either group. The authors conclude that the lymphatic microsurgical preventive healing approach is a valid technique for prevention of breast cancer–related lymphedema. We applaud the authors for this well-written study and contribution to the literature. As with all procedures aimed at lymphedema prevention and treatment, the question remains: Do these procedures really prevent lymphedema or just delay the onset? Based on a cohort study of patients followed up over a 20-year period, approximately three-fourths of patients will develop breast cancer–related lymphedema in the first 3 years after mastectomy, with the remaining patients developing breast cancer–related lymphedema at a rate of almost 1 percent per year.3 Therefore, longer follow-up is often warranted to assess the effects of radiation fibrosis and the long-term patency of these microsurgical techniques. In addition, the ability of these techniques to prevent lymphedema in the face of future infections, trauma, or weight gain that may occur over a patient's lifetime is still unanswered. Of interest, the authors performed preoperative lymphoscintigraphy in all study patients and used the Kleinhans transport index4–6 to quantify visual findings on lymphoscintigraphy, which was found to have a statistically significant predictive value in identifying at-risk patients. Some women who develop breast cancer–related lymphedema may have lymphatic abnormalities, such as a weaker lymphatic pump or increased lymph flow (or afterload), that predispose them to the development of breast cancer–related lymphedema.7 By potentially using this information and identifying at-risk patients, we may be able to preoperatively select patients for preventative techniques and provide more directed counseling to these patients. This may also balance the cost-benefit of such techniques in the new era of health care cost containment and allow for increased support of specialized training in microsurgical techniques that currently may limit the practicality of its widespread use. We appreciate the comments on our study and look forward to future contributions by Dr. Campisi and his skilled group of colleagues. Melissa A. Crosby, M.D. David W. Chang, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.