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Page 6 of 15 Friedman et al. Plast Aesthet Res 2023;10:23 https://dx.doi.org/10.20517/2347-9264.2022.100

lymphadenectomy. Even with careful consideration and selection of the recipient vein, venous back-
bleeding and inadequate recipient vein length are two technical challenges that impede the success of ILR
and lead to aborting procedures intraoperatively. Recently, our team has instituted routine use of a lower
[78]
extremity vein graft to overcome these venous-related complications . In this technique, a 5 cm target vein
is identified by ultrasound as a superficial secondary or tertiary branch of the greater saphenous vein in the
medial lower leg, caudal to the medial epicondyle of the knee. This segment is ideally selected to ensure the
presence of at least two branches or one venous valve, which can be visualized on ultrasonography. The vein
is then harvested and anastomosed to the axillary vein tributary, maintaining the orientation of the vein
graft in order to preserve the proper directionality of the venous valve. Since utilizing a lower extremity vein
graft during ILR, our intraoperative aborted case rate was reduced from 14% to 0%, thereby suggesting the
[78]
promising effects and potential utility of this innovation to mitigate venous-related complications .
Furthermore, the harvest of the lower extremity vein graft was performed synchronously with the ALND
[78]
and therefore did not increase the intraoperative time of the overall operation .

Of note, additional preventative surgical approaches to reducing the risk of lymphedema have been
proposed, including peripheral supermicrosurgical anastomoses and prophylactic lymph node
transplantations and lymphatic flaps [79-83] . Prophylactic peripheral lymphovenous bypasses offer an
interesting approach which would essentially eliminate the effect of adjuvant radiotherapy which is usually
targeted to the nodal region. The challenge of this prophylactic approach is identifying anatomically which
lymphatic channels should be bypassed. Prophylactic lymph node transplantations and lymphatic flaps offer
a promising approach. However, the surgeon must carefully balance the morbidity of the donor site with
the relative risk reduction of lymphedema development [83,84] .

LYMPHATIC ANATOMY
Despite continued evidence demonstrating the effectiveness of ILR for the prevention of BCRL, there are
several barriers that may hinder the progress and advancement of this approach within the field of
lymphatic surgery. Firstly, ILR remains a technically demanding procedure that is not frequently covered by
health insurance . Additionally, there are a limited number of lymphatic centers and surgeons formally
[85]
trained in lymphatic microsurgery, and therefore patients are often required to travel long distances to
[86]
undergo ILR . While the incidence of BCRL after ALND and RLND approaches 25-30%, around 70% of
patients do not ever develop lymphedema. Although the occurrence of BRCL may be moderate, counseling
all patients regarding the risk of lymphedema after oncologic surgery is necessary for proper patient
management. In addition, discussing the benefits of ILR and obtaining thorough informed consent
enhances patient autonomy and understanding of medical information . Importantly, identifying the
[87]
individuals with the highest risk for BCRL development will allow us to overcome resource constraints and
deliver this procedure to those who need it the most.

We believe that a better understanding of individual variations in lymphatic anatomy will help identify
those patients in greatest need for ILR. To date, there is no modern comprehensive compendium or map of
normal lymphatic anatomy and most of our current foundational knowledge has been obtained from
cadaveric dissections that predate the twentieth century . However, more recent efforts have been made to
[88]
further the anatomic knowledge of the lymphatic system. In 2016, Suami et al. described the lymphosome
concept [Figure 3], which is defined as predictable areas of the body in which the lymphatics will reliably
drain to a designated group of lymph nodes [89,90] . This concept has advanced our understanding of lymphatic
anatomy and allowed for more accurate predictions regarding the location of major lymphatic channels. A
detailed appreciation of lymphatic anatomy based on the lymphosome concept may help guide lymphatic
surgeons in selecting which lymphatic channels to bypass when multiple transected channels are identified