Lynn M Orfahi - Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, United States
Tony C.T.Huang - bDivision of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, United States
Wei F Chen - Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, United States

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 minimallyinvasive nature and highly favorable outcomes in the hands of experiencedsupermicrosurgeons. As LVA techniques are refined and improved, interest is risingin utilizing it to prevent the manifestation of disease in the first place. Lymphaticmicrosurgical preventive healing approach (LYMPHA), also known as immediatelymphatic reconstruction (ILR), is the most widely used approach. It involvesperforming axillary LVA immediately following axillary lymphadenectomy. Whilepreliminary results are favorable, the high-pressure proximal axillary venous branchesused in ILR and the site’s vulnerability to damage from radiotherapy endanger thelong-term patency of these anastomoses. Moreover, a theoretical oncologic concernexists regarding creating a direct conduit for the remaining malignant cells in the axillainto the circulation. Finally, coordinating ILR with axillary lymphadenectomy createssignificant logistical challenges. Delayed, distally-based LVA (DD-LVA) hasemerged as an alternative method that avoids these issues. This article presents anoverview of the development of preemptive lymphatic reconstruction, and the seniorauthor’s approach to the novel technique of DD-LVA.

lymphedema, supermicrosurgery, lymphaticovenicular anastomosis, lymphatic reconstruction, distal delayed LVA