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Friedman et al. Plast Aesthet Res 2023;10:23 https://dx.doi.org/10.20517/2347-9264.2022.100 Page 5 of 15

Figure 1. Comprehensive workflow of immediate lymphatic reconstruction (ILR) following axillary lymph node dissection (ALND).

Figure 2. Potential recipient vein options in the axilla for immediate lymphatic reconstruction (reused with permission, Coriddi et al.,
2020, Plastic and Reconstructive Surgery Global Open [67] ).

popular for ILR, is found coursing through the level 1 axillary lymph nodes, originating perpendicular from
the axillary vein, 2 cm anterior to the thoracodorsal vessels. Due to its proximity to arm lymphatic channels,
it has become an ideal candidate for the procedure . Unfortunately, this proximity to the axillary lymph
[67]
nodes also places this vein at risk for transection and removal during axillary lymph node excision. In this
case, any of the previously mentioned veins can be used as an alternative [74,75] .

The recipient vein requires adequate length, which we have found to be ideally ≥ 5cm, as it must be long
enough to reach the arm lymphatic vessels while avoiding undue tension on the anastomosis. The presence
of at least one venous valve is vital for preventing venous back-bleeding through the site of the anastomosis.
Significant back-bleeding can overwhelm the lymphatic system, given the pressure differential across the
anastomosis, thereby preventing afferent lymphatic flow. Furthermore, the size of the recipient vein is a
critical consideration as the lymphatic channels are significantly smaller than that of their venous
counterparts. To help alleviate this size discrepancy, multiple lymphatic channels can be intussuscepted into
the vein, or if the lymphatic vessels are large enough, an end-to-end anastomosis can be performed with a
small vein [67,76] . Utilization of venous branches of the recipient vein has also become an effective method to
[67]
optimize the size-matching of the lymphatic channel to the recipient vein . Moreover, each branch point is
likely to contain a valve, thereby further preventing the backflow of venous blood . Of note, unlike
[77]
lymphovenous bypasses for chronic lymphedema performed in the distal extremity where preoperative
ultrasound can assist in identifying reflux-free veins [74,75] , this is not possible pre-operatively in preventative
cases as the veins are deeper and their availability and physiology may be altered following