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Ewing et al. Plast Aesthet Res 2024;11:22 https://dx.doi.org/10.20517/2347-9264.2024.11 Page 9 of 15

Figure 3. Radiation considerations in the breast cancer patient. ADM: acellular dermal matrix; PAP: profunda artery perforator; DIEP:
deep inferior epigastric perforator; msTRAM: muscle-sparing transverse rectus abdominis myocutaneous.

A recent study in Japan compared conservative management versus combined-modality LVA and
[94]
compression therapy for lymphedema in early breast cancer . The single-center retrospective analysis
found that surgical lymphovenous anastomosis and compression therapy were more efficacious than
conservative treatment alone, citing reductions in limb circumference and cellulitis incidence . Newer
[94]
literature advocates for multidisciplinary approaches combining surgical modalities and medical therapies.
Ciudad et al. present a multi-national algorithm for breast cancer-related lymphedema . The authors
[95]
employed the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) and found that the
addition of suction-assisted lipectomy to LVA significantly reduced limb circumference, compared to LVA,
[95]
VLNT, and combined DIEP flap and VLNT .
In this review, we discuss the management of breast cancer-related lymphedema, including lymphovenous
bypass and vascularized lymph node transfer. While each method has its own advantages and limitations,
newer research calls for multidisciplinary and multimodal algorithmic treatment aimed at both prevention
and treatment.

SUMMARY
Despite a growing interest in pre-pectoral implant-based reconstruction, fat grafting, and pedicled
latissimus dorsi flaps, autologous breast reconstruction remains a favorable surgical approach for a
previously irradiated field due to its acceptable complication risk profile and improved patient satisfaction
and quality of life. In this review, we presented technical microsurgical pearls for radiated breasts, including
the enhancement of flap vascularity, expanded dissection of recipient vessels, postoperative anticoagulation,
and various salvage conduits. Furthermore, we propose an algorithm that describes the multiple approaches
to timing free flap reconstruction for the previously irradiated patient. Lastly, we reviewed the prevention of
lymphedema through several surgical techniques including LVB, LVA, and VLNT. When caring for the
previously irradiated patient, we must consider all levels of care in which a paradigm shift in breast
reconstruction may occur. This could mean a change in microsurgical techniques, reconstructive timing,
preoperative optimization, and postoperative care.