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Page 2 of 10 Park et al. Plast Aesthet Res 2023;10:40 https://dx.doi.org/10.20517/2347-9264.2022.98

INTRODUCTION
With the advancement of microsurgical and supermicrosurgical techniques, new surgical methods for
breast cancer-related lymphedema (BCRL) have been introduced. Since the introduction of
supermicrosurgery-based lymphovenous anastomosis (LVA) and microsurgery-based vascularized lymph
[1-3]
node transfer (VLNT), surgeons worldwide have utilized these techniques with promising results .

Furthermore, new imaging modalities, including lymphoscintigraphy, indocyanine green (ICG)
lymphography, high-frequency ultrasonography, and magnetic resonance (MR) lymphangiography, have
been applied to the field of lymphedema, allowing more accurate and sensitive detection of lymphatic
vessels and lymphatic fluid collection . While LVA has previously been performed predominantly in
[4-7]
early-stage lymphedema patients, based on these advanced images, the indications for LVA have been
widened to include advanced lymphedema patients as well .
[8,9]

However, some researchers have postulated that LVA alone may not be effective in chronic lymphedema
patients [10,11] , particularly patients in the late 2 and 3 stages of The International Society of Lymphology (ISL)
lymphedema stage. As previously shown in pathophysiological studies, chronic inflammation and lymphatic
fluid stasis cause deterioration of the pumping mechanism of the lymphatic vessels along with programmed
cell death of lymphatic endothelial cells . Together, they cause tissue fibrosis and progressive pathological
[12]
changes in the lymphatic lumen until the lymphatic vessel becomes sclerotic and nonfunctioning. In these
cases, providing a bypass through LVA at the distal lymphatic system where there is insufficient lymphatic
flow may not be effective in the long run.

In these advanced BCRL patients, providing healthy lymphatic vessels and lymph nodes (lymphatic
complex) through VLNT has effectively reduced arm volume and improved the patient's quality of life [3,13,14] .
Compared to lower extremity lymphedema patients, BCRL patients have the advantage of having an
anatomical recipient candidate for lymph node transfer, the axilla. Therefore, in theory, utilizing both of
these methods with very different fundamental mechanisms can maximize the outcome for these patients.
More recently, the combination of LVA and VLNT has been introduced to combine the effects of these
procedures in treating BCRL patients [15-17] . This paper will discuss our protocol and techniques for
performing combined LVA and VLNT in BCRL patients.

FLAP OPTIONS, PATIENT SELECTION, AND OPERATIVE DETAILS
Decision-making of surgical methods in late-stage lymphedema
Aside from radical debulking procedures, there are three main options for advanced BCRL: LVA, VLNT,
and suction-assisted lipectomy(SAL). While technical details and indications of each procedure vary
between different surgical centers, selecting the most suitable surgical method or a combination of
techniques to maximize the outcome and patient satisfaction is the common goal for all surgeons.

Our protocol for lymph node donor selection
At our institution, we primarily use three donor sites for VLNT: right gastroepiploic artery-based omental
flap, deep inferior epigastric perforators (DIEP) flap with the superficial inferior epigastric artery (SIEA) or
superficial circumflex iliac artery (SCIA) based lymph node flap, and superficial circumflex iliac artery
perforator (SCIP) flap [Figure 1].

The donor selection depends mainly on two factors: the need for breast reconstruction and the contracture
level of the axilla [Figure 2]. If the patient wants simultaneous breast reconstruction, the DIEP flap
harvested with groin lymph node is our preferred choice. Patients who do not need or desire breast