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Page 10 of 18 Laustsen-Kiel et al. Plast Aesthet Res 2024;11:17 https://dx.doi.org/10.20517/2347-9264.2024.32

Another surgical technique is the vascularized lymph node transfer (VLNT) from other areas in the body.
[179]
Inguinal lymph node transfer was first shown to reduce lymphedema of the leg in 1982 , and later,
Becker et al. reported a decrease in lymphedema after inguinal lymph node transfer to the axilla in 20 out of
[180]
22 patients . The vascularized omental lymph node transfer (VOLT) flap to the axillae was first published
by Nakajima in 2006 ; a systematic review has found VOLT improves lymphedema, but it highlights that
[181]
[182]
further studies are needed to identify appropriate patients for the technique . One advantage of the VOLT
flap is that the removal of the omentum does not induce iatrogenic lymphedema at the donor site , which
[183]
[184]
is a risk with lymph node transfer from the inguen or axillae . This risk can potentially be reduced using
ICG-A and lymphoscintigraphy preoperatively, as proposed by Pons et al. . Recently, Teven et al.
[185]
performed a minimally-invasive approach utilizing the da Vinci Single-Port robotic system, only requiring
[183]
[186]
two port holes , but there is an ongoing debate on the appropriate method of harvesting the flap .
Combining surgical and decongestive approaches has recently been investigated, where a study found LVA
[187]
combined with compression therapy to improve cellulitis in early-stage BCRL . Another study combined
CDT and MLD with either LVA or VLNT, dependent on patient anatomy, for stage I and II
lymphedema . For stage III lymphedema, patients also had suction-assisted lipectomy, which previous
[188]
studies showed to reduce lymphoedema in the arm and be an effective technique in end-stage
lymphedema [189,190] . 10 of the patients included had combined breast reconstruction with DIEP flaps and
[188]
VLNT . No difference in complication rate between GE-VLNT and GE-VLNT combined with DIEP was
found in seroma, dehiscence, and lymph node flap loss .
[188]
In recent years, the combination of breast reconstruction with lymphedema surgery in a single surgery has
been explored. A retrospective chart review found VLNT to have a similar complication profile with or
[191]
without autologous breast reconstruction . A 2020 study by Chang et al. showed that combining the DIEP
flap with VLNT combined with lymphaticovenous anastomosis was safe and might be superior to VLNT
[192]
alone . The patients were followed up 12 months post-operatively, both cohorts improved their
lymphedema symptoms. A recent review found a higher risk of seroma, wound problems, and donor site
pain when comparing VLNT combined with autologous breast reconstruction and isolated VLNT .
[193]
However, as they report, surgical expertise with VLNT is increasing, and the incidence of seroma has
[193]
decreased for their own cohort during the last five study years . Taranto et al. compared delayed breast
reconstruction using DIEP flaps with and without VLNT and found no significant difference in donor site
complication rate, no difference in BREAST-Q scores, but a notable circumference reduction in the
lymphedema arm and statistically significant improvement in lymphedema QoL questionnaire (LYMQOL)
after surgery .
[194]

PERSPECTIVES
When deciding what kind of treatment and follow-up program breast cancer patients should follow in a
specific country, economics and feasibility will naturally influence the decision, as resources are divided
unevenly around the world. Newer prediction strategies, such as the utilization of artificial intelligence (AI),
[195]
could help physicians decide on which patients should be monitored more closely , or perhaps benefit
from preventive BCRL surgery. However, AI is limited by the data it is built on, and it is therefore essential
to produce and publish data of high quality, both negative and positive findings, to strengthen these
computational tools.

CONCLUSION
Based on the current review of the literature, no certain causality between BCRL and breast reconstruction
was found. The surgical and oncologic treatment modalities for breast cancer, as well as patient BMI, are