Immediate lymphatic reconstruction: an overview

Breast cancer related lymphedema (BCRL) is estimated to affect up to 50% of patients after lymph node surgery, with risk factors including axillary lymph node dissection (ALND), radiation therapy, and higher body mass index (BMI). BCRL causes significant morbidity for patients and is currently a chronic, progressive disease with no known medical or surgical cure. Immediate lymphatic reconstruction (ILR) is a promising surgical intervention performed at the time of lymph node dissection to prevent secondary lymphedema. Using axillary reverse mapping (ARM), lymphatic channels draining the upper extremity can be identified and preserved during lymph node surgery. Lymphatic channels that are unable to be preserved are bypassed to a nearby recipient vein, physiologically restoring lymphatic drainage from the extremity into the venous system. This lymphovenous bypass (LVB), also called lymphatic microsurgical preventive healing approach (LYMPHA), is most often performed with microsurgical techniques, though other techniques such as simplified or S-LYMPHA have also been described. Therefore, ILR requires close communication and a learning curve for both the oncologic and reconstructive surgeon. Early clinical outcomes show that ILR reduces the incidence of lymphedema, though short follow up times and heterogeneity between studies make it difficult to draw conclusions. As part of a series on BCRL, the purpose of this review article is to provide an overview of ILR with a focus on the historical background, surgical considerations, current outcomes data, and future directions of ILR.