Surgical Prevention of Breast Cancer-Related Lymphedema: Delayed Distal Lymphaticovenicular Anastomosis– An Alternative to the Classic LYMPHA Technique

Breast cancer-related lymphedema (BCRL) is a devastating potential complication of axillary lymphadenectomy and radiotherapy. Several effective surgical treatment measures now exist, including lymphaticovenicular anastomosis (LVA), vascularized lymph node transplant (VLNT), and vascularized lymph vessel transplant (VLVT) for fluid-predominant disease, and liposuction and radical excision for solid-predominant disease. Super-microsurgical LVA is of particular interest, owing to its minimally invasive nature and highly favorable outcomes in the hands of experienced supermicrosurgeons. As LVA techniques are refined and improved, interest is rising in utilizing it to prevent the manifestation of disease in the first place. Lymphatic microsurgical preventive healing approach (LYMPHA), also known as immediate lymphatic reconstruction (ILR), is the most widely used approach. It involves performing axillary LVA immediately following axillary lymphadenectomy. While preliminary results are favorable, the high-pressure proximal axillary venous branches used in ILR and the site’s vulnerability to damage from radiotherapy endanger the long-term patency of these anastomoses. Moreover, a theoretical oncologic concern exists regarding creating a direct conduit for the remaining malignant cells in the axilla into the circulation. Finally, coordinating ILR with axillary lymphadenectomy creates significant logistical challenges. Delayed, distally-based LVA (DD-LVA) has emerged as an alternative method that avoids these issues. This article presents an overview of the development of preemptive lymphatic reconstruction, and the senior author’s approach to the novel technique of DD-LVA.