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Page 2 of 15 Sarrami et al. Plast Aesthet Res 2024;11:13 https://dx.doi.org/10.20517/2347-9264.2024.06

mastectomies develop BCRL and the incidence significantly increases in patients receiving axillary lymph
[1-4]
node dissection and radiation . The mainstay of treatment for lymphedema continues to be complete
[5-7]
decompression therapy; however, if conservative management fails, surgical intervention may be needed .
The two current options for lymphedema management are debulking and physiologic procedures.
Debulking is used in patients with severely nonfunctional lymphatic systems and provides symptom relief.
New treatment modalities focus on physiologic reconstruction using lymphovenous bypass or vascularized
lymph node transfer (VLNT), aiming to restore lymphatic function and improve lymph flow [5,7,8] . By
combining autologous flaps with physiologic lymphatic surgery, postmastectomy patients with BCRL can
obtain aesthetic breast reconstruction and lymphedema management in a single operation.

The aim of lymph node transfer to an area of lymphatic obstruction is to create a healthy lymphatic bridge
and restore physiologic flow. At the recipient site, the VLNT will form lymphatic connections and promote
new channel growth [9-11] . This is mediated by the production of VEGF-C which stimulates
lymphangiogenesis in the donor and recipient tissue [10,12,13] . Additionally, it is hypothesized that the
transferred lymph nodes act as a pump that absorbs interstitial fluid [14-16] . Lymph flow has been mapped
[10]
through spontaneous connections with the VLNT flap, which then drains into the venous outflow . Early
success and improved understanding of VLNT physiology have led to the rapid development of numerous
lymph node transfer options and modalities .
[5]
Several studies have shown the efficacy of combining autologous breast reconstruction with VLNT [4,8,16] .
Chimeric flaps using inguinal nodes, lateral thoracic nodes, or omentum aim to construct an aesthetic
breast and improve lymphatic function. In this article, we will describe the surgical options that accomplish
autologous breast reconstruction and restore the lymphatic network in a single operation.

PATIENT SELECTION
The combined autologous breast reconstruction and lymph node transfer are indicated for patients with
upper extremity lymphedema and significant soft tissue breast defects. These patients tend to have a history
of breast cancer with mastectomies and usually have received axillary dissection and radiation [2,17] . If
lymphedema symptoms progress after 6 months of conservative management, surgical intervention is
advised . A multidisciplinary team is necessary to optimize patients for the operation. It is preferred that
[5]
breast cancer patients complete radiation treatment with their oncologist and wait 6 months before
attempting surgery [Table 1]. Additionally, improving the patient’s health and nutrition can play a large role
in the outcomes of autologous reconstruction and lymphedema surgery [4,5,7] . Prior surgical history, such as
cesarean section or thoracic node dissection, is also important and may limit certain flap options.

IMAGING
Though the utility of perforator mapping is debated for autologous free flap breast reconstruction, it is
widely accepted that lymphography is a vital component of lymphatic surgery [18,19] . Commonly,
intraoperative reverse lymphatic mapping of the donor site is utilized to identify lymph nodes draining the
extremity that should be avoided during flap harvest. In this technique, pioneered by Dayan et al.,
technetium is injected into the webspace of the extremity to identify nodes draining the leg using a gamma
probe . Congruently, indocyanine green (ICG) is injected in the trunk and identifies nodes to be included
[18]
within the flap using a near-infrared imaging device. The main purpose of this practice is to prevent donor
site lymphedema of the extremity [5,14,16] . In this technique, it is recommended that a 10-second count with
the gamma probe that is within 10% of the hottest node should not be harvested. Isosulfan blue can be used
in place of technetium to visualize the lymphatic vessels intraoperatively. Other imaging options include
lymphoscintigraphy, which can be obtained preoperatively to roughly identify nodes draining the extremity.