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Page 8 of 15 Ewing et al. Plast Aesthet Res 2024;11:22 https://dx.doi.org/10.20517/2347-9264.2024.11

[72]
approaches . Prospective trials and retrospective reviews also match these assertions, with results that
suggest patient quality of life and aesthetic perception are similar between immediate and delayed, and that
immediate reconstruction in the setting of PMRT does not appear to affect patient outcomes [73,74] .

This shift in interest and results favoring the immediate approach in research have new clinical implications
for the debate between immediate and delayed reconstruction. Timing for the delayed-immediate approach
avoids flap exposure to radiation while retaining the aesthetic outcomes of the immediate approach. The
delayed-immediate approach is also applicable to high-risk patients at risk of flap complications. However,
recent research suggests that immediate reconstruction is a reliable option in low-risk patients and can be
offered as a treatment alternative. Figure 3 provides a preferred algorithm by the senior author for radiation
considerations in the breast cancer patient. When consulting patients on reconstruction, an immediate
approach may be a valid option for patients, particularly if their radiotherapy will be administered over a
small area or at a low dosage that the flap can tolerate [67,75,76] . However, this shift should be tempered by prior
studies that have demonstrated an increased risk of complications with flap radiation exposure, including
flap contracture, volume loss, and fat necrosis [74,77] . As a result, based on existing literature, surgical planning
should consider offering delayed-immediate reconstruction as an option for patients with PMRT.

Autologous reconstruction with lymph node transfer to prevent lymphedema in the radiated breast
With the aforementioned effects of radiation on tissue quality and the resultant vascular compromise,
coupled with the effects of surgical dissection, breast reconstruction patients are prone to lymphedema,
[78]
especially after ALND . An estimated 3%-8% of patients develop lymphedema even after just SLNB alone,
with other known risks such as neoadjuvant/adjuvant chemoradiation (CRT) and obesity . The
[79]
management of lymphedema is outside the scope of this special topic; however, it sometimes requires
surgical techniques. Technological advances such as microscopes, and evolutionary techniques of
lymphovenous bypass (LVB) and lymphovenous anastomosis (LVA) have demonstrated efficacy in
[80]
reducing sequelae of lymphedema . However, equally important as treating lymphedema is preventing it.
Vascularized lymph node transfer (VLNT) includes the microsurgical transplant of lymph nodes and an
associated vascular pedicle from a donor to a recipient site. Lymph node transfer is believed to stimulate
lymphangiogenesis, thereby improving lymphatic drainage of the recipient region and consequently
[81]
reducing lymphedema . The procedure can be useful for both treating and preventing lymphedema. It is
[82]
typically reserved for more advanced cases and poor candidates for LVA/LVB , but can also be considered
at the time of the index surgery.

Various techniques exist, and there are several options for nodal harvest. Some of the most commonly used
basins for VLNT include the supraclavicular , submental , lateral thoracic , inguinal (which can be
[85]
[83]
[82]
[84]
[86]
[87]
taken at the time of DIEP harvest, i.e., a single operation) , and the omentum (which can also be taken at
the harvest of DIEP or msTRAM) [86,88] . Although options for successive or combined operations are feasible,
[89]
combined operations may have better results and also demonstrate better postoperative patient-reported
quality of life (QOL) . Recently, the omental lymph node transfer has gained popularity, as current
[90]
research continually demonstrates that it is a safe and feasible procedure without the additional risk of
donor site lymphedema .
[91]
Regardless of the nodal basin used, clinical judgment and provider discretion are paramount. Donor site
morbidity such as scar location or lymphedema risk must be accounted for, and further studies are
warranted to determine the long-term outcomes of such flaps and lymph node transfers [92,93] .