A comprehensive treatment algorithm for patients requiring simultaneous breast and lymphedema reconstruction based on lymph node transfer

Background: Secondary upper limb lymphedema may progress in a deleterious condition that affects the quality of life of breast cancer survivors. Post-mastectomy patients, who also suffer from refractory lymphedema, often require a simultaneous breast reconstruction and lymphedema treatment. Autologous breast reconstruction, which remains the gold standard, can be combined with a free vascularized lymph node transfer to restore the impaired lymphatic circulation. Here we describe the algorithmic approach which is used in our department when managing post-mastectomy lymphedema patients, based on lymphedema stage, and body characteristics. Methods: We analyze the parameters that should be considered in order to select the appropriate breast-reconstruction method, including body characteristics, breast size, previous radiotherapy, availability of donor lymph nodes and characteristics of the lymphedematous affected limb. We also present our data on simultaneous breast and lymphedema reconstruction, during the period 2011–2020. Method for breast reconstruction, donor site of lymph node flap, number of lymph nodes contained into the flap, affected limb volume improvement and infection episodes, need for secondary operations at the breast or limb, postoperative complications and patients’ satisfaction level, are recorded and analyzed. Results: A total of 69 mastectomy and upper limb lymphedema patients were included in the study, 35 underwent partial breast reconstruction with local flaps or lipofilling, coupled with autologous lymph node transfer, while 34 underwent a combined procedure of lymphedema and total breast reconstruction (deep inferior epigastric perforator flaps n=24, fat-augmented latissimus dorsi flaps n=8, implants n=2). Inguinal lymph nodal flaps were used in all cases; a mean of 4.1 lymph nodes were contained in the flaps. The need for secondary surgeries was assessed as 1.4 per patient. A mean volume reduction of 54.8% between upper limbs was documented (52.9% for Stage I, 54.3% for Stage II and 61% for Stage III lymphedema) at the mean 4years and 8 months follow-up; mean infection episodes were reduced from 1.2 to 0.2 per patient. All patients confirmed their subjective satisfaction. Conclusions: Simultaneous breast and lymphedema reconstruction is an effective combined procedure for addressing both mastectomy and upper-limb lymphedema in a single operation. Given the complexity and technical requirements of these demanding surgeries, the use of algorithms may help reconstructive surgeons to make a systematic approach and appropriate planning of the procedure, in order to obtain better postoperative results.