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removed or damaged by radiotherapy for breast cancer treatment, can be replaced by autologous healthy
[27]
LNs harvested from an untreated donor site . VLNT should therefore improve BCRL because new
lymphatic connections are expected to form between new afferent and efferent lymphatics sprouting from
the transferred LNs and residual lymphatics at the recipient site. VEGF-C secreted by transplanted LNs also
[28]
seems to have an important role in this mechanism . Additionally, VLNTs are believed to absorb lymph
like a sponge, before redirecting it into the vascular network like a pump [19,29,30] .

This technique is especially appealing to patients who have undergone ALND (with or without radiation
[21]
treatment) and with scarring in the axilla . As donor LNs replace axillary LNs after ALND and/or
radiotherapy, the most common recipient site is obviously the axilla [2,27] . Insetting of the flap in the axilla
[27]
should be preceded by surgical release of scars as the scar itself may impede lymphatic flow . Scar release
would also provide a healthy environment for lymphangiogenesis. Other VLNT recipient sites have
also been described, such as the wrist and elbow [30,31] , where distal insetting in the upper limb can take
advantage of gravity for the flap to absorb excess fluid.

Donor LNs can be harvested from different sites with the groin being the most popular [2,27] . Other donor
[19]
sites include the supraclavicular area, submental area, lateral thoracic area and intra-abdominal LNs . In
the groin, the LN-flap is supplied by the superficial circumflex iliac artery or superficial inferior epigastric
[32]
artery. Scaglioni and Suami found that in cadavers, the superficial inguinal LNs can be divided into 3
subgroups: the abdominal, medial thigh and lateral thigh groups. The abdominal group is utilized in VLNT.
The LNs to be taken are located above the inguinal ligament, and superficial and lateral to the common
femoral vessels. The harvesting of LNs below the inguinal ligament, medial to the femoral vessels or deep
to the fascia of the thigh must be avoided because these LNs drain the lower limb and iatrogenic lower limb
lymphedema may result [2,33] . Data now show that LN-flap harvesting is not a complication-free procedure
[33]
and VLNT from the groin can lead to lower limb lymphedema .
As such, reverse lymphatic mapping techniques are gaining popularity with VLNT procedures. These
imaging techniques aim to identify the LNs that drain lymph from the donor limb, to avoid inadvertent
harvest during VLNT. Indocyanine green (ICG)-lymphography has been shown to be useful for this
purpose. ICG is injected intradermally into the foot web spaces, absorbed by lymphatic vessels and
transported proximally to the LNs draining the lower limb. Lymphatic vessels and nodes can be visualized
in real-time with a camera that captures the near-infrared fluorescence emitted from ICG so that the
[2]
draining LNs can be spared . Similarly, patent blu dye V can be injected intradermally at the level of the
[2]
anterior superior iliac spine with the aim of identifying LNs draining the lower abdomen .

Lymphatico-venous anastomosis
The lymphatico-venous anastomosis (LVA) [Figure 2] technique bypasses the lymphatic obstruction,
creating a shunt between the lymphatic and blood circulation in the affected limb. The first LVA was
performed several decades ago [34,35] , but the currently accepted technique was developed after the advent of
[36]
supermicrosurgery .

First, a small quantity of patent V blue dye is injected intradermally, a few centimeters distal to where the
surgical incision will be performed. The dye is absorbed by lymphatic vessels which then turn blue and
become easier to identify. Multiple anastomoses between superficial subcutaneous lymphatic vessels and
venules are then performed, either end-to-end or end-to-side, in the affected upper limb. Lymph is thus
[2]
diverted into the venous circulation . This technique is widely accepted for the treatment of early BCRL,
when lymphatic vessels with residual functionality can still be demonstrated, as lymph has to be pumped
into venules through the LVA. ICG-lymphography and magnetic resonance lymphography can thus be
useful for preoperative assessment for the presence of, and location of contractile lymphatics suitable for
[2]
LVA .