Physiologic Lymphedema Surgery: Current Treatments and Future Trends

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is well-written, well-structured, and free of any major errors. However, it primarily reviews existing procedures for lymphedema without presenting new insights, original research, or particularly novel perspectives. While it provides a comprehensive overview, it may not offer significant new information for readers already familiar with the field. I recommend the authors consider adding a unique perspective, such as a discussion of emerging trends, unresolved challenges, or a critical analysis of current methodologies (meta-analysis for istance), to enhance its value to the readership.

Author Response

Comments: The manuscript is well-written, well-structured, and free of any major errors. However, it primarily reviews existing procedures for lymphedema without presenting new insights, original research, or particularly novel perspectives. While it provides a comprehensive overview, it may not offer significant new information for readers already familiar with the field. I recommend the authors consider adding a unique perspective, such as a discussion of emerging trends, unresolved challenges, or a critical analysis of current methodologies (meta-analysis for instance), to enhance its value to the readership.

 

Response: Thank you for this comment. We have added to our paper a discussion of ongoing challenges to the field. Additionally, we have added a section discussing our own experiences as a high volume center and our approach to treatment. Unfortunately, a meta-analysis is beyond the scope of this current paper, however this would be an excellent idea for future critical examinations of methodologies.

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting and well-structured paper discussing current treatments for secondary lymphedema, focus on physiological techniques. The manuscript is well supported by relevant references. I would like to offer a few suggestions that may help improve the quality of the paper:

• Please consider including a clear statement of the study’s aim or purpose in the abstract.
• There are a few minor spelling errors in the manuscript that should be corrected:
• Line 131: "altnerative" → "alternative"
• Line 143: "configutarion" → "configuration"
• Line 185: "gardient" → "gradient"
• In the section on vascularized lymph node transfer (VLNT), it would be valuable to comment on whether the number of lymph nodes included in the flap influences outcomes according to literature.
• It could be interesting to include an additional section or discussion on lymph node-to-vein anastomosis, as this technique is gaining attention in the field.

Author Response

This is an interesting and well-structured paper discussing current treatments for secondary lymphedema, focus on physiological techniques. The manuscript is well supported by relevant references. I would like to offer a few suggestions that may help improve the quality of the paper:

Comment: Please consider including a clear statement of the study’s aim or purpose in the abstract.

Response: Thank you, this has been added to the abstract

Comment: There are a few minor spelling errors in the manuscript that should be corrected:

• • Line 131: "altnerative" → "alternative"
  • Line 143: "configutarion" → "configuration"
  • Line 185: "gardient" → "gradient"

Response: Thank you, these have been corrected.

Comment:  In the section on vascularized lymph node transfer (VLNT), it would be valuable to comment on whether the number of lymph nodes included in the flap influences outcomes according to literature.

Response: Thank you, we have added a discussion of this and relevant references to this section.

Comment: It could be interesting to include an additional section or discussion on lymph node-to-vein anastomosis, as this technique is gaining attention in the field.

Response: Thank you, a section on lymph node-to-vein anastomosis has been added.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the effort the authors have made in addressing my previous comments, particularly the inclusion of a section detailing the specific therapeutic procedures used at their center. This addition provides helpful context and practical insight for readers interested in the implementation of these treatments.

However, despite this improvement, I still have some reservations about the manuscript’s overall contribution to the existing literature. As noted previously, the manuscript is well-written, well-structured, and free of major errors. Nevertheless, it largely reviews established procedures for lymphedema management without offering significant new insights, original data, or particularly novel perspectives.

While the comprehensive overview may be useful for readers less familiar with the topic, it may not add substantial value for those already knowledgeable in this field. To strengthen the manuscript’s impact, I encourage the authors to further develop a unique angle—such as an in-depth discussion of emerging trends, unresolved clinical or methodological challenges, or a critical analysis of current approaches through, for example, a meta-analysis.

Such additions would help distinguish the work from existing reviews and enhance its relevance and interest to the journal’s readership

Author Response

Thank you for the comments on our revised manuscript. The reviewer has suggested that the manuscript should have “a unique angle - such as an in-depth discussion of emerging trends, unresolved clinical or methodological challenges, or a critical analysis of current approached through, for example, a meta-analysis.” This revision already has a long section of emerging developments in lymphedema surgery (section 5) and a section about unresolved challenges (section 5.5), so we believe these suggestions have been addressed. A meta-analysis is outside the scope of this invited manuscript. The purpose of this review is to provide an in-depth overview of the current and future surgical options for lymphedema, for a target audience with varying levels of pre-existing knowledge about this topic. Therefore, we have not incorporated the suggestion of a meta-analysis into our manuscript, and we would like to keep the revised manuscript as previously submitted.