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

Abstract

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.

Distally Based Lymphatic Microsurgical Preventive Healing Approach—A Modification of the Classic Approach

“…Recognizing similar shortcomings of the LYMPHA technique and advantages of moving the LVA distally, Orfahli et al proposed the use of a distally based LVA. 18 However, due to scheduling constraints, they were unable to coordinate the oncologic resection and lymphatic reconstruction into one event. We did not face these logistical constraints in our center and were able to perform surgery concurrently with the breast resection or reconstruction, thereby reducing operative time.…”

“…utilising the LYMPHA technique, we did not encounter any situation where dLYMPHA was not suitable in the upper limb. Recognising similar shortcomings of the LYMPHA technique and advantages of moving the LVA distally, Orfahli et al proposed the use of a distally based LVA [18]. However, due to scheduling constraints, they were unable to coordinate the oncologic resection and lymphatic reconstruction into one event.…”

“Double Barrel” Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon’s Repertoire

“…Due to its commonality, the topic of vein versus lymphatic mismatch has been dealt extensively in the medical literature. 20 Many solutions have been proposed to combat this difficulty, including traditional beveling of the smaller lymphatic vessels so as to increase their lymphatic caliber and reduce the size discrepancy. 21 Although this technique may be well suited for macroscopic structures or conventional microsurgery, it is not a very fruitful exercise in lymphatic surgery where the vessels in question are in the range of less than 0.5 mm.…”