Subsequent Surgery to Be Expected

We would like to thank Gerber et al. for their clear overview of breast reconstruction following cancer treatment (1). We agree with their conclusion that secondary autologous breast reconstruction is the procedure of choice after post-mastectomy radiotherapy.

We think that the profunda artery perforator (PAP) flap, which has been promoted by Robert J. Allen since 2010, is superior to the DIEP flap. Therefore, we prefer it in situations where free tissue transfer is indicated for breast reconstruction.

As mentioned by Gerber et al., subsequent surgeries can be expected in breast cancer patients after mastectomy, radiotherapy and then breast reconstruction. Regrettably, the authors did not mention the lymphedema of the upper extremity, even though it occurs in up to 49% of patients (2, 3). Using advanced microsurgical and supermicrosurgical techniques, such as free lymph node transfer, lymphaticovenous anastomosis (LVA) and lymphatic vessel transfer, lymphedema can be greatly improved, as we have observed in our own breast cancer patients for many years now (4).