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Laustsen-Kiel et al. Plast Aesthet Res 2024;11:17 https://dx.doi.org/10.20517/2347-9264.2024.32 Page 5 of 18

Table 2. Staging of lymphedema according to ISL
Clinical presentation Pathophysiology
Stage 0 No visible sign of swelling Lymphatic insufficiency/impaired lymph transport
Latent or subclinical Subjective symptoms might be present Subtle changes in fluid composition
Stage 1 Pitting may occur Early accumulation of fluid
Spontaneously reversible Possibly hyperkeratosis High in protein
ICG shows dilated lymphatics with irregular pulsation
Dermal backflow
Stage 2 Pitting is still present, but the arm is firmer than in Increased fibrosis and tissue changes, including accumulation of
Spontaneously stage 1 adipocytes
irreversible
Stage 3 No pitting Irreversible swelling with significant tissue fibrosis
Lymphostatic Skin changes: thickening and hyperkeratosis Chronic inflammation
elephantiasis Possible warty overgrowths ICG will often show diffuse accumulation of dye in the skin

increasingly aiming to avoid breast deformities and achieve contralateral symmetry by applying oncoplastic
surgery with volume displacement or replacement techniques.

LYMPH NODE DISSECTION
Assessment of the lymph nodes is a crucial part of breast cancer treatment. The risk of developing
lymphedema and other arm morbidities is highly dependent on the extent of the axillary surgery, as
[83]
demonstrated by a recent study analyzing the risk of BCRL . Studies indicate that women undergoing
axillary lymph node dissection (ALND) - both with and without adjuvant radiotherapy - have a significantly
higher incidence of lymphedema compared to patients undergoing sentinel lymph node biopsy (SLNB)
under the same conditions [10,70,83-86] . However, BCRL is still reported after SLNB with postmastectomy
radiation therapy (PMRT) and increasing BMI as reported risk factors .
[87]
[83]
RADIOTHERAPY
PMRT and lymphedema have been extensively examined, with multiple trials assessing the difference in
toxicity of different radiation schedules [88-94] . A review and meta-analysis from 2020 showed that while
PMRT serves its purpose of decreasing local and regional recurrence of breast cancer, it also plays a key role
in the development of lymphedema .
[95]

The impact of radiation on breast reconstruction was recently investigated; a meta-analysis found
immediate autologous free flap reconstruction to be associated with superior flap survival compared to
delayed autologous reconstruction, indicating that autologous immediate breast reconstruction (IBR) is safe
even when PMRT is planned . However, a large cohort study from 2020 found PMRT to increase the
[96]
5-year cumulative complication rate for both autologous, two-stage implant-based, and direct-to-implant
reconstruction types . The outcome of a direct-to-implant breast reconstruction relies on the mastectomy
[97]
skin flap viability, and even though modalities - such as ICG-A - lowered the rate of mastectomy skin
necrosis , the intraoperative decision to deter from one-stage implantation to an expander could
[98]
potentially bias the complication outcome. Ultimately, the decision on the type of reconstruction should not
solely rely on a single factor, such as PMRT.

BREAST RECONSTRUCTION
Breast reconstruction surgery has become a significant part of the breast cancer pathway, with the primary
aim of breast reconstruction to improve QoL and breast-related satisfaction for the patient. Increased
information, a rise in risk-reducing mastectomies , changes in legislation in some countries, such as the
[99]
[100]
United States , and the suggestion that breast reconstruction increases health-related QoL outcomes after