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Sarrami et al. Plast Aesthet Res 2024;11:13 https://dx.doi.org/10.20517/2347-9264.2024.06 Page 11 of 15

[37]
can result in rippling of the breast if positioned improperly .

Autologous reconstruction
There is a growing body of literature finding that autologous flaps without lymph nodes can improve
lymphatic flow [3,47] . Slavin et al. first recognized the ingrowth of lymphatic channels into free tissue transfers
[9]
[48]
in 1997 . This has been more recently supported by Yamamoto et al. . In his retrospective study, 38
patients underwent indocyanine green lymphography after free flap or replant operations and 63% showed
lymphatic flow restoration. Still, a superior lymphatic response with VLNT has been shown in a handful of
studies [3,26,47] . In a systematic review by Siotos et al. comparing autologous breast reconstruing in BCRL
patients with and without VLNT, 84% of patients who received the chimeric flap option reported
[3]
symptomatic improvement versus 22% of patients who had reconstruction alone . Lymph node transfer
appears to offer a more robust lymphatic response which improves patients’ overall outcomes. Additionally,
breast reconstruction and VLNT can be completed in a staged approach, but preventative and early
treatment of lymphatic disruptions is ideal for the BCRL population.

DISCUSSION
As the number of patients anticipated to develop lymphedema increases with growing breast cancer
treatment, plastic surgeons will certainly see patients who are suffering from postmastectomy lymphedema
while also seeking breast reconstruction. Due to advancements in lymphedema surgery and a growing
understanding of the lymphatic system, several reconstructive options are now available [7,8,23] . The aims of
surgical intervention are to create aesthetic breasts and promote lymphatic flow to holistically treat these
complex patients in a single operation.

Patients seeking reconstruction following breast cancer treatment often present difficult microsurgical cases,
especially when complicated by the presence of lymphedema. These patients typically have undergone
axillary dissection and radiation which disrupts normal and healthy blood flow [2,17] . As lymphedema
progresses, the cutaneous and subcutaneous tissue becomes fibrotic and is associated with recurrent
infections . While most microsurgeons can perform autologous breast reconstruction safely, this multi-
[49]
faceted procedure typically requires additional training and experience to produce optimal results [5,32] . The
increased risks associated with adding a VLNT to an autologous flap can lead to severe complications.
However, surgical advancements have continued to make this reconstructive option safe and efficient [8,18] .

Lymphedema affecting the chest and abdomen as a result of breast cancer treatment is underdiscussed in
the literature. Similar to upper extremity lymphedema, truncal lymphedema can cause pain, swelling, and
fibrotic skin . Currently, there are no individualized treatment methods for this disease process.
[50]
Traditional management using complete decompression therapy or compression garments is often
inadequate. Autologous reconstruction in conjunction with VLNT to the axilla may help restore lymphatic
flow to the chest by providing healthy tissue and creating new lymphatic pathways. Of note, breast
reconstruction using an omental flap and ADM pocket, as discussed earlier, is not an ideal treatment option
for patients with chest lymphedema. This reconstructive option, similar to implants, requires healthy
mastectomy skin flaps otherwise it may result in severe complications .
[37]
The recipient site of a VLNT flap for treatment of upper extremity lymphedema can be the axilla, elbow, or
wrist [14,22] . Any site can be combined with simultaneous breast reconstruction. Recipient site location
depends largely on surgeon preference. Those who support the theory that lymph nodes act as a pump to
absorb interstitial fluid prefer to position the VLNT flap distally. This allows the flap to work with
gravity [14,15] . Additionally, distal flaps may be especially useful in patients who have localized lymphedema of