Sir:FigureWe read with great interest the article entitled “Immediate Breast Reconstruction and Lymphedema Incidence”1 by Crosby et al. The article presents a study that focused on upper extremity lymphedema onset after various postmastectomy immediate reconstructive options (i.e., expander/implant, latissimus dorsi myocutaneous flap/implant, autologous flap alone). In particular, the study outcomes revealed that the reconstructive method did not seem to affect lymphatic impairment, whereas high body mass index, axillary interventions, and high numbers of positive lymph nodes were associated with the incidence of lymphedema. We would like to discuss the role of primary prevention of lymphatic injuries2 following breast cancer treatment, with specific reference to lymphatic microsurgical prevention of secondary lymphedema, and want to make some comments on this matter. In the literature, the incidence of arm lymphedema after sentinel lymph node biopsy varies from 0 to 13 percent, but lymphedema occurrence after axillary lymph nodal dissection varies from 7 to 77 percent.3 This wide variability is attributable to the definition and method to determine lymphedema, the different length of follow-up, the different number of positive lymph nodes, postoperative irradiation, and body habitus (body mass index).4–6 In addition, considering the anatomical point of view, there exist so-called arm derivative lymphatic pathways, among which the main ones are represented by the cephalic bundle running to the supraclavicular nodes through the deltopectoralis way (the Mascagni pathway) and the posterior bundles that run to the posterior scapular nodes through the tricipital way (the Caplan pathway). These derivative pathways are among the possible explanations for why lymphedema does not always develop after axillary nodal dissection, chemotherapy, and radiotherapy for breast cancer treatment. It is possible to identify afferent lymphatics and nodes coming from the lymphatic pathway draining the upper extremity. In the blue node draining the arm, the absence of cancer cells was confirmed both by frozen sections and definitive histologic findings. Nevertheless, the identification of the efferent lymphatics, which is mandatory to truly preserve the lymphatic flow of the arm, is almost impossible because the lymphatics departing the blue nodes join the common lymphatic pathway draining the breast.7 We have recently reported a prospective, randomized, group-control trial8 in which 46 consecutive women who underwent complete axillary lymph nodal dissection were divided into two groups. The control group received axillary lymph nodal dissection alone, whereas the other group underwent the lymphatic microsurgical preventing healing approach at the same time of axillary lymph nodal dissection. Lymphatic microsurgical preventing healing approach treatment consisted of lymphatic-venous anastomoses between afferent lymphatics, coming from the upper extremity, and a collateral branch of the axillary vein. The outcome was statistically significant and showed an incidence of lymphedema in the control group of 30.43 percent in comparison with the lymphatic microsurgical preventing healing approach group, where the incidence reported was 4.34 percent. Primary prevention of secondary lymphedema following breast cancer treatment should always be mandatory. Patient assessment with preoperative lymphoscintigraphy8 (lymphatic transport index) is an easy method of evaluating the predictability of postoperative upper extremity lymphedema development, giving the surgeon a reasonable tool devoted to the patient's quality-of-life improvement. In this way, taking into consideration all modifiable and unchangeable (constitutional) risk factors, it is possible to prevent lymphatic injuries with a feasible microsurgical technique.9,10 Corrado C. Campisi, M.D. Unit of Plastic and Reconstructive Surgery Department of Surgery IRCCS University Hospital San Martino IST National Institute for Cancer Research Genoa, Italy Lorenz Larcher, M.D. Section of Plastic, Aesthetic, and Reconstructive Surgery General Hospital Linz Linz, Austria Rosalia Lavagno, M.D. Department of Experimental Surgery and Microsurgery University of Pavia, Pavia Italy Stefano Spinaci, M.D. Unit of Lymphatic Surgery Michaela Adami, M.D. Unit of Plastic and Reconstructive Surgery Francesco Boccardo, M.D., Ph.D. Unit of Lymphatic Surgery Pierluigi Santi, M.D. Unit of Plastic and Reconstructive Surgery Corradino Campisi, M.D., Ph.D. Unit of Lymphatic Surgery Department of Surgery IRCCS University Hospital San Martino IST National Institute for Cancer Research Genoa, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.