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Jabbour et al. Plast Aesthet Res 2021;8:43 https://dx.doi.org/10.20517/2347-9264.2021.59 Page 5 of 12

surgical oncologists who are able to preserve the vessels for the immediate LVB [Figure 5]. All LVB are
performed using the standard LVB technique, where an end-to-end anastomosis is performed between the
lymphatic and recipient vein. In certain circumstances, when the axillary dissection is more extensive due to
advanced disease, there are a limited number of suitable recipient veins. Rather than gathering the
lymphatic channels into a single vein using intussusception, the authors still favor a true anastomosis to
ensure patency of the anastomoses using the PREVAIL technique. We do not recommend sacrificing the
main or both venae comitantes (VC) of the thoracodorsal vessels as this would preclude the use of a pedicle
latissimus dorsi flap in the future. However, one VC can be sacrificed, or a branch such as the serratus
branch is often available and can serve as a recipient vein. In other circumstances, when only a single larger
vein is available, a double-barrel approach can be performed, performing a true anastomosis of two
lymphatic vessels into a single vein, again avoiding intussuscepting the lymphatic vessel into the vein
[Figure 6].

While most studies again have demonstrated success in reducing the risks of lymphedema, longer follow-up
studies are needed to confirm the true efficacy. Further, other studies have also claimed to have significant
reductions in the risk of lymphedema without using super microsurgical techniques. However, most studies
are limited to one year or a year and a half, with only one study that followed patients up to 4 years .
[30]
Nonetheless, it is the author’s opinion that lymphedema cannot be cured once a patient truly has developed
lymphedema, and therefore, prevention is the key to managing the risk of lymphedema in high-risk patients
and preserving patients’ quality of life.

Vascularized lymph node transfer
The second primary technique for surgical treatment of lymphedema is a VLNT. While there is a paucity of
literature comparing one donor site to another, most studies have demonstrated significant benefits and
improvement with each respective donor site [31-35] . A number of different donor sites have been described,
and the decision for which donor site to utilize is based on the availability of donor sites and patients’
acceptance of risks and complications. While the submental donor site has no risk of donor site
lymphedema, patients are cautioned regarding the prevalence of the scar and the potential risk of injury to
the marginal mandibular nerve. There are rare reports of donor site lymphedema following the harvest of
the supraclavicular nodes, but again the scar may be apparent and should be discussed [36,37] . We also favor
the right side to avoid injury to the thoracic duct, which can result in a difficult complication if it is injured
on the left side. The inguinal donor site has a well-concealed scar and is a donor site that can provide
additional volume, which is often needed following a complete scar release. However, precautions are
necessary to avoid the risk of precipitating lymphedema in the lower extremity following harvest. The intra-
abdominal options are very appealing due to a well-concealed scar and no reported risks of donor site
lymphedema; however, patients should understand the risks of entering the abdomen . The mesenteric
[38]
nodes and the omentum/gastroepiploic nodes are both increasing in popularity [Figure 7]. Injury to
adjacent structures, adhesions, and risks of bowel obstruction and an incisional hernia should all be
thoroughly discussed with patients. Harvest of the omentum or the gastroepiploic lymph nodes has also
been associated with pancreatitis, while harvest of the mesenteric nodes can also lead to ischemic bowel,
necessitating a bowel resection [39,40] .

Combined breast reconstruction and vascularized lymph node transfer
For patients suffering from upper extremity lymphedema secondary to breast cancer treatment who are also
interested in breast reconstruction, the combined approach is the authors’ recommended approach as the
patient can obtain an aesthetic autologous breast reconstruction in combination with a lymph node transfer
in a single operation with minimal risks [41-43] [Figure 8]. For all patients undergoing a combined deep
inferior epigastric perforator (DIEP) and VLNT, preoperative lymphoscintigraphy and reverse mapping are