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

Abstract

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally-terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively ( p = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

Keywords: breast cancer; lymphedema; lymphovenous anastomosis; microsurgery.

Fig. 1

End-to-end LVA showing good flow of patent blue flowing across anastomosis. (black arrow: vein, white arrowhead: lymphatic vessel) LVA, lymphaticovenular anastomosis.

Fig. 2

An LVA formed by anastomosing two lymphatic channels (white arrowhead) to one venule (black arrow), showing good flow of patent blue across anastomosis. LVA, lymphaticovenular anastomosis.

Fig. 3

Left arm showing incisions (black arrows) near medial upper arm and over radial wrist.

Fig. 4

Intraoperative positioning for microscopes to allow simultaneous dLYMPHA and breast flap inset. dLYMPHA, distally based Lymphatic Microsurgical Preventive Healing Approach.