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Advances in the diagnosis and treatment of breast cancer have significantly improved survival rates. Breast cancer-related lymphedema is the most common mid-and long-term complication after breast cancer surgery, which seriously affects the quality of life. Breast reconstruction can not only restore the shape of the breasts after mastectomy, but also reduce the occurrence of lymphedema to some extent. Immediate autologous breast reconstruction combined with lymphatic venous anastomosis (LVA) or vascularized lymph node transfer (VLNT) can effectively prevent lymphedema. Delayed breast reconstruction combined with LVA or VLNT can achieve the dual benefits of restoring the appearance and treating lymphedema at the same time. The autologous tissue flap can function as a bridge to promote lymphatic drainage, thus enhancing the treatment of lymphedema. The advances mentioned above in surgical techniques have provided a basis for decision making in breast reconstruction and the prevention and treatment of breast cancer-related lymphedema, and have also brought hope for improving the quality of life of patients.

Background:  Breast cancer-related lymphedema (BCRL) is a cyclical, progressive disease that begins at the time of axillary dissection and worsens in the setting of adjuvant oncologic therapies. The paradigm of lymphedema management in these patients is shifting from therapeutic surgeries and decongestive therapy to preventative surgery with immediate lymphatic reconstruction (ILR)., Methods:  After institutional review board approval, a prospective database was maintained of all patients undergoing ILR. Patients were excluded if they had preoperative lymphedema or expired during the study period. All ILR were performed by the senior author. A control group was established with standardized physician delivered phone surveys of patients who had axillary dissection for breast cancer (same oncologic surgeon cohort) prior to the implementation of ILR at the same institution. The study and control groups were matched based on history of adjuvant radiation and body mass index., Results:  A cohort of patients between 2016 and 2019 with 2 years of follow-up after undergoing ILR (77 patients) were matched with those who did not undergo lymphatic reconstruction (94 patients). The incidence of lymphedema in the study group undergoing ILR was 10% ( N  = 8). In comparison, the incidence in the cohort who did not undergo lymphatic reconstruction was 38% ( N  = 36; p  < 0.01). Patients with ILR had 92% lower odds of developing lymphedema ( p  < 0.01)., Conclusion:  ILR can significantly reduce the risk of developing BRCL in high-risk patients at 2 years of follow-up. Patients receiving adjuvant radiation therapy are more likely to develop BCRL after ILR compared with those who do not. Ongoing studies include investigation aimed at identifying patients most at risk for the development of BRCL to help target intervention as well as elucidate factors that contribute to the success of ILR., Competing Interests: None declared., (Thieme. All rights reserved.)

Breast cancer related lymphedema (BCRL) is a chronic condition with a detrimental impact on psychosocial and physical well-being. Lymphaticovenous anastomosis has shown promising results in alleviating physical symptoms and increasing quality of life in patients with BCRL. The aim of the study is to evaluate the effect on health related quality of life (HrQol) after LVA surgery versus conservative treatment in patients with BCRL. The study is a prospective, multicenter randomized controlled trial. Adult women with unilateral BCRL, with early stage lymphedema and viable lymphatic vessels were included. The primary outcome measure was HrQol measured by the lymphedema functioning disability and health (Lymph-ICF) questionnaire. The secondary outcomes were volume difference measured by the water displacement method; the Upper Extremity Lymphedema (UEL) index; and daily use of the compression garments after 3 and 6 months. For this interim analysis 46 patients per group were included. There was a significant improvement in the domains in physical and mental function in the Lymph-ICF questionnaire in the LVA group after 6 months, (- 16.46 ± 18.5, p < 0.05, - 10.12 ± 29.5, p < 0.05 respectively). However, there was no statistical difference in the total score of the Lymph-ICF after 6 months in both groups (LVA-group; - 8.57 ± 22.6, p > 0.05, CDT-group; - 2.65 ± 18.2, p < 0.05). Furthermore, there was no significant volume reduction in both groups (LVA-group: 20.04 ± 196.40, p = 0.497, CDT: 33.98 ± 189.87, p = 0.236). In the LVA group, 41% partially of completely stopped wearing the compression garments after six months whereas in the CDT group 0% discontinued to use of compression garments. LVA resulted in improvement of the domains physical and mental function of the Lymph-ICF. Limb volume did not significantly improve after 6 months. However, around 42% could completely or partially stopped with the use of compression garments in the LVA group. The current results are promising, however longer follow up is required to assess long term effect of LVA for secondary lymphedema. Clinical Trial Registration: NCT02790021 registered on 03/06/2016., (© 2024. The Author(s).)

This single-centre retrospective cohort study aimed to clarify the superiority of treatment by comparing the outcomes of lymphaticovenular anastomosis with compression therapy and conservative treatment centred on compression therapy in the early stage of breast cancer-related lymphoedema. Data were collected from all patients treated for breast cancer-related lymphoedema between January 2015 and December 2022. The patients were classified into conservative treatment and surgical treatment groups. The upper extremity lymphoedema index value was calculated, based on five circumference values of the upper extremity and body mass index, to compare the 6-, 12-, 18- and 24-month outcomes between the groups. Of 101 patients with breast cancer-related lymphoedema, 81 (conservative treatment: 52; surgical treatment: 29) were included in the analysis. The therapeutic effect was significantly higher in the surgical treatment group than in the conservative treatment group, when comparing the rate of change in oedema at 6 (-6.6% ± 7.3% vs. 0.9% ± 7.5%; p < 0.001), 12 (-7.3% ± 6.2% vs. 2.9% ± 8.6%; p < 0.001), 18 (-7.6% ± 8.0% vs. 3.9% ± 9.2%; p < 0.001) and 24 (-5.6% ± 6.0% vs. 4.4% ± 10.7%; p < 0.001) months. The incidence of cellulitis increased in the conservative treatment group (from 9.6% to 15.4%), whereas it was suppressed in the surgical treatment group (from 13.8% to 0%). Conservative treatment centred on compression therapy increased oedema over time; however, lymphaticovenular anastomosis with compression therapy effectively reduced oedema., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Up to one in three patients may go on to develop breast cancer-related lymphedema (BCRL) after treatment. Immediate lymphatic reconstruction (ILR) has been shown in early studies to reduce the risk of BCRL, but long-term outcomes are limited because of its recent introduction and institutions' differing eligibility requirements. This study evaluated the incidence of BCRL in a cohort that underwent ILR over the long term., Methods: A retrospective review of all patients referred for ILR at the authors' institution from September of 2016 through September of 2020 was performed. Patients with preoperative measurements, a minimum of 6 months of follow-up data, and at least one completed lymphovenous bypass were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence., Results: A total of 186 patients with unilateral node-positive breast cancer underwent axillary nodal surgery and an attempt at ILR over the study period. Ninety patients underwent successful ILR and met all eligibility criteria, with a mean patient age of 54 ± 12.1 years and median body mass index of 26.6 kg/m 2 [interquartile range (IQR), 24.0 to 30.7 kg/m 2 ]. The median number of lymph nodes removed was 14 (IQR, eight to 19). Median follow-up was 17 months (range, 6 to 49 months). Eighty-seven percent of patients underwent adjuvant radiotherapy, and among them, 97% received regional lymph node irradiation. The overall rate of lymphedema was 9% at the end of the study period., Conclusions: With the use of strict follow-up guidelines over the long term, the authors' findings support that ILR at the time of axillary lymph node dissection is an effective procedure that reduces the risk of BCRL in a high-risk patient population., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations., Patients and Methods: In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed., Results: Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05)., Conclusions: We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention., (© 2023. Society of Surgical Oncology.)

Background: Breast cancer treatment is the principal cause of lymphedema in the upper extremities. Breast cancer-related lymphedema (BCRL) treatments were previously based on conservative therapy; surgical treatments are alternative options that could be highly beneficial, especially for patients who are not responsive to conservative therapy. The main aim of this study was to describe and critically assess the risk of bias of randomized clinical trials (RCTs) and systematic reviews (SRs) on surgical treatment for BCRL., Methods: We conducted an evidence mapping review according to the methodology proposed by Global Evidence Mapping (GEM). An update was done for our previous systematic search in MEDLINE, EMBASE, CENTRAL (Cochrane), and Epistemonikos from the year 2000 onward. We assessed the risk of bias for the RCTs and SRs using the RoB-2 and ROBIS tools, respectively., Results: Two surgical RCTs and eight SRs were found among the 47 surgical studies that met the eligibility criteria. The overall risk-of-bias assessments of these studies were rated as some concerns (six outcomes) and high risk (three outcomes) for the measured outcomes among the RCTs and as a high risk of bias (five studies) and low risk (three studies) for the included SRs., Conclusions: The overall evidence in the literature on surgical treatment for BCRL is low, as there are few published RCTs and SRs, and the risk-of-bias assessment for the majority was rated as high risk of bias or with some concerns. High-quality studies are needed to improve evidence-based decision-making by surgeons and patients., Competing Interests: Conflicts of interest All remaining authors have declared no conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo., Methods: Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data., Results: Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant., Conclusion: Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema., Clinical Question/level of Evidence: Risk, V., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background:  Lymphedema affects up to 34% of patients after breast cancer treatment but remains underdiagnosed and undertreated. Here, we use area deprivation index (ADI), a measure of neighborhood socioeconomic disadvantage, to determine how socioeconomic status may affect risk for and diagnosis of breast cancer-related lymphedema., Methods:  Records of patients who underwent surgical treatment of breast cancer between 2017-2020 were examined. Patients' nine-digit ZIP codes were utilized to determine their deprivation level as a national ADI percentile, and those fitting into the most and least deprived quartiles were compared with evaluate lymphedema risk factors and incidence., Results:  A total of 1,333 breast cancer patients were included, 812 (61%) of whom resided within the most disadvantaged ADI quartile nationally, and 521 within the least disadvantaged quartile. The most deprived group had higher rates of diabetes, obesity, and regional breast cancer, and received more extensive surgeries (7.5% modified radical mastectomy vs 1.9%, p  < 0.001) and chemotherapy compared with the least disadvantaged quartile. The most disadvantaged cohort were more often at extreme risk of lymphedema utilizing the Risk Assessment Tool Evaluating Lymphedema Risk (9.1% versus 2.5%, p  < 0.001); however, the incidence of lymphedema diagnoses was not significantly higher (13% vs 12%, p > 0.9). Logistic regression showed that the most deprived ADI quartile had 44% lower odds of a lymphedema diagnosis in comparison to the least deprived quartile., Conclusion:  Residing in more socioeconomically disadvantaged neighborhoods is associated with lower odds of a lymphedema diagnosis, despite higher rates of risk factors for lymphedema, suggesting significant underdiagnosis in this population., Competing Interests: S.N.C., M.J.F., K.V., G.B.S., and J.M.C. have nothing to disclose. J.M.S. is a co-founder and equity holder of LifeSprout, and a consultant for 3M., (Thieme. All rights reserved.)

Background: Whether the breast reconstruction modality could influence the long-term development of post-mastectomy lymphedema has been little investigated. The present study aimed to evaluate the potential association of the breast reconstruction method with the incidence of lymphedema over an extended follow-up period., Methods: Patients with breast cancer who underwent immediate reconstruction from 2008 to 2014 were reviewed. They were categorized into three groups according to the reconstruction method: tissue expander/implant, abdominal flaps, and latissimus dorsi (LD) muscle flaps. Differences in the cumulative incidence of lymphedema by the reconstruction method were analyzed, as well as their independent influence on the outcome. Further analyses were conducted with propensity-score matching for baseline characteristics., Results: In total, 664 cases were analyzed with a median follow-up of 83 months (402 prostheses, 180 abdominal flaps, and 82 LD flaps). The rate of axillary lymph node dissection was significantly higher in the LD flap group than in the other two groups. The 5-year cumulative incidences of lymphedema in the LD flap, abdominal flap, and prosthesis groups were 3.7%, 10.6%, and 10.9%, respectively. In multivariable analyses, compared to the use of the LD flap, that of tissue expander/implant and that of abdominal flaps were associated with increased risks of lymphedema. A similar association was observed in the propensity-score matching analysis. The use of abdominal flaps or prostheses was not associated with the outcomes., Conclusions: Our results suggest that the method of immediate breast reconstruction might be associated with the development of postmastectomy lymphedema., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Purpose: We investigated whether a one-stage combination of vascularized lymph node transfer (VLNT) with water jet-assisted liposuction (WAL) can be safely performed and results in improved patient outcomes such as a greater reduction in arm volume when treating chronic breast cancer-related lymphedema (BCRL)., Methods: In this retrospective cohort study, we included all patients from our encrypted lymphedema database treated for chronic BCRL with VLNT or VLNT + WAL who had a minimum follow-up of two years. We analyzed patient-specific variables including arm circumferences as well as patient-reported outcomes before and after surgery as well as surgery time, surgery-related complications and patient satisfaction., Results: Only the mean preoperative differences of the circumferences between the lymphedematous and the unaffected arm in individual patients showed a statistically significant difference between treatment groups (p < 0.05). Indeed, patients treated with VLNT + WAL had consistently larger differences in individual sets of arms and therefore more pronounced chronic BCRL. The mean surgery time was significantly longer in the VLNT + WAL group (p < 0.05). Complications were seldom and similar in both groups. Using a numeric rating scale, the level of patient satisfaction following treatment did not differ significantly between groups (p = 0.323)., Conclusions: Our findings suggest that a one-stage combination of VLNT with WAL does not result in more complications even though it also entails a longer surgery time. This is acceptable as secondary interventions resulting in overall longer surgery times and higher costs can be avoided. A one-stage combination might be especially favourable for patients suffering from more severe chronic BCRL., (© 2022. The Author(s).)

Background:  Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL., Methods:  We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis., Results:  A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate., Conclusion:  These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Purpose: Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy., Methods: We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas., Results: Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P < 0.05)., Conclusions: Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone., (© 2022. The Author(s), under exclusive licence to The Japanese Breast Cancer Society.)

Introduction: Lymphedema is a condition which heavily impacts patients QoL. For patients who desire autologous breast reconstruction, lymph nodes can be included in the Deep Inferior Epigastric Artery (DIEP) flap combining vascularized lymph node transfer and autologous breast reconstruction., Material and Methods: Patients who received autologous breast reconstruction with a DIEP flap in combination with vascularized lymph nodes were included in this study. Volume measurements pre and post-surgery were analyzed and surveys including two versions of the ULL-27 questionnaire to measure QoL before and after surgery were send., Results: In total, 45 out of 64 patients returned the questionnaires. The average follow up was 51 months. The total ULL-27 score increased with 12.6 points on average (p = 0.00). The subdomain scores (physical, psychological and social) also significantly increased (p = 0.00). In addition 69% of patients were able to decrease physiotherapy, 63% of patients were able to decrease compression garment usage and the incidence of skin infections decreased in 6 patients out of 7 patients who had recurrent skin infections prior to surgery. The volume difference between the affected and the healthy arm did not significantly change (407 ml-406 ml, p = 0.988)., Conclusions: Vascularized lymph node transfer in combination with DIEP flap breast reconstruction can cause a significant improvement on lymphedema related QoL, even when a volume difference decrease is absent. It can also decrease compression garment usage and reduce the need for physiotherapy. Future prospective studies should evaluate these findings and identify patients that benefit most from such procedures., (Copyright © 2022. Published by Elsevier Ltd.)

Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.

Background: Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients., Methods: Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician., Results: Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p < 0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer-related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005)., Conclusions: This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer-related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer-related lymphedema in high-risk patients., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Lymphedema is an edematous condition that afflicts the postmastectomy breast cancer population, with diminished quality of life with substantial financial costs. The factors predictive of postmastectomy lymphedema development in breast cancer patients are unknown. The objective was to evaluate the trends over time in lymphedema development and the risk factors predictive of lymphedema-related events within 2 years of mastectomy., Methods: Using the New York Statewide Planning and Research Cooperative System multicenter deidentified database from 2010 to 2016, a total of 65,543 breast cancer postmastectomy female patients (mean age, 59 ± 20 years) were identified across 177 facilities. The breast cancer patients were followed for any 2-year postmastectomy lymphedema-related events. A multivariable model identified predictors of 2-year lymphedema using eligible variables involving demographics, comorbidities, and complications. Elixhauser score was defined as a comorbidity index based on International Classification of Diseases codes used in hospital settings., Results: Overall, 5.2% (n = 3409) of the breast cancer postmastectomy patients experienced a lymphedema-related event within 2 years of initial surgery. Over time, 2-year postmastectomy lymphedema rates have more than doubled from 4.62% in 2010 to 9.75% in 2016 (P < 0.001). Two-year postmastectomy lymphedema rates varied significantly by mastectomy procedure type: 5.69% of the mastectomy-only procedures, 5.96% of the mastectomies with lymph node biopsies, and 7.83% of the mastectomies with lymph node dissections (P < 0.0001). Full mastectomies had a greater 2-year lymphedema rate of 7.31% when compared with partial mastectomies with 2.79% (P < 0.0001). The top predictive risk factors for a lymphedema-related event included higher Elixhauser score, prolonged hospitalization for mastectomy, more recent mastectomy procedure, obesity, younger age, non-Asian race, Medicaid insurance, and hypertension (all P's < 0.01)., Conclusions: Although more recent postmastectomy lymphedema rates may not be as high as historical estimates, the 2-year postmastectomy lymphedema rates have more than doubled from 2010 to 2016 requiring further elucidation as well as continued focus on treatment. Furthermore, risk factors were identified that predispose postmastectomy breast cancer patients to developing lymphedema. Given these findings, perioperative screening seems warranted to proactively identify, educate, and monitor postmastectomy patients at greatest risk of future lymphedema development., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background:  Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients., Methods:  This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones., Results:  Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p  = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean -11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p  = 0.000). No complications were observed during this period., Conclusion:  LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results., Competing Interests: None declared., (Thieme. All rights reserved.)

Abstract: Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. At present, physical methods and surgical methods can be used for treatment. Surgical operations are mainly based on lymphovenous anastomosis and vascularized lymph node transfer. For these 2 surgical methods, we analyzed and compared the literature review and our own clinical experience. We summarized the differences between the 2 surgical techniques and the selection methods. We hope to help more young plastic surgeons and breast doctors understand how to treat upper limb lymphedema through surgical methods and help patients improve their quality of life., Competing Interests: Conflicts of interest and sources of funding: The study was presented at the 7th Congress of the World Association of Plastic Surgeons of Chinese Descent (WAPSCD), Hangzhou, China. The authors have declared they have no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We sought to determine if bioimpedance spectroscopy (BIS) measurements can accurately assess changes in breast cancer-related lymphedema (BCRL) in patients undergoing lymphovenous bypass (LVB)., Methods: Patients undergoing LVB for BCRL refractory to conservative treatment from 1/2015 to 12/2018 were identified from an IRB-approved prospectively maintained database at a single institution. All breast cancer patients were assessed with baseline BIS measurements prior to any oncologic surgery and serial BIS during follow-up office visits including before and after LVB. Clinicopathologic information, LVB operative details, and pre- and post-LVB operative BIS measurements were collected. Analysis focused on clinically significant BIS change, defined as two standard deviations (SD), and comparing LVB anastomosis to BIS changes., Results: During the study timeframe, nine patients underwent LVB for treatment of BCRL. The majority (78%) received radiation, taxane chemotherapy, and underwent axillary dissection. An average of 5.6 LVB anastomoses were performed per patient. The average change in BIS following LVB was a 3SD reduction, indicating a clinically significant change. This improvement was stable over time, with persistent 2SD reduction at 22 months postoperatively. The number of LVB anastomoses performed did not significantly correlate with the degree of BIS change., Conclusions: This is the first study to utilize BIS measurements to assess response to LVB surgical intervention for BCRL. BIS measurements demonstrated clinically significant improvement after LVB, providing objective evidence in support of this surgical treatment for BCRL. BIS changes should be reported as key objective data in future studies assessing BCRL interventions, including response to LVB.

Objective: To explore the clinical effects of free deep inferior epigastric perforator flap carrying lymphatic groin flap for treatment of upper limb lymphedema after radical mastectomy and breast reconstruction. Methods: From October 2014 to December 2016, 10 female patients, aged 37-60 (48±8) years, who had lymphedema in the upper limb after radical mastectomy, were admitted to Department of Oncology Plastic Surgery of Hunan Cancer Hospital. Three patients suffered recurrent erysipelas infections, and 4 patients suffered consistent neuropathic pain in the upper limb. Free deep inferior epigastric perforator flap carrying lymphatic groin flap was used for breast reconstruction and lymphedema treatment. Operation was performed by 2 surgeon groups including recipient site prepare group and flap harvest group. In the 10 patients, the length of the flaps was (26.2±0.3) cm, the width of the flaps was (13.4±0.4) cm, and the thickness of the flaps was (3.4±0.3) cm. All the donor sites in the abdomen were closed directly. The choices of vascular pedicles and vessels in the recipient sites, operation time, complications, operation effects, and follow-up were recorded. Results: (1) Bilateral vascular pedicle was adopted in flaps of 5 patients. Unilateral vascular pedicle was adopted in flaps of 5 patients. The recipient vessels were proximal and distal ends of internal thoracic vessels in 4 cases, the proximal end of thoracodorsal vessels in 3 cases, the proximal end of internal thoracic vessels in 2 cases, and the proximal end of internal thoracic vessels and thoracodorsal vessels in 1 case. (2) The operation time of the patients was 330-480 (406±55) min. (3) Subcutaneous edema was observed in flaps of 2 patients and donor site of 1 patient, which were all healed by dressing change therapy. The other flaps survived successfully. The reconstructed breasts were in good shape and elasticity. Nine patients had different degrees of relief in lymphedema in the upper limb. All 10 patients were followed up for 6 to 28 months, no one had recurrent erysipelas infections, and neuropathic pain in the upper limb was relieved in 2 patients. Only linear scar was left in the donor sites of 10 patients, and the function of abdomen was not affected without related complications. Conclusions: Free deep inferior epigastric perforator flap carrying lymphatic groin flap can simultaneously accomplish breast reconstruction and upper limb lymphedema treatment, which is worthwhile to be popularized in clinic.