Effectiveness of the lymphatic microsurgical preventive healing approach for avoiding breast cancer–related arm lymphedema

Authors: Yono S, Hannoudi A, Chamseddine H, Rama S, Bensenhaver JM, Yoho D, Tepper D, Evangelista MS, Nathanson SD, Atisha DM.

Affiliation: Division of Plastic and Reconstructive Surgery, Henry Ford Health, Detroit, MI.

Journal: The Breast, July 2025

PMID: 40682911

Key takeaways

• In 187 ALND patients (121 LyMPHA; 66 ALND-only), LyMPHA reduced BCRL risk by ~47% (HR 0.53; 95% CI 0.28–0.98; P = 0.043).

• Kaplan–Meier curves showed significantly lower cumulative BCRL incidence with LyMPHA (P = 0.003).

• Patient-reported functional impairment was lower with LyMPHA (median 4.7% vs 11.6%; P = 0.045).

• Drain duration was shorter with LyMPHA (median 13 vs 15 days; P = 0.042) with no increase in complications.

Background

Breast cancer–related lymphedema (BCRL) impairs function, increases infection risk, and burdens patients and health systems. Preventive strategies at the time of axillary lymph node dissection (ALND) are a priority.

Objective

Evaluate whether immediate lymphatic reconstruction using LyMPHA at the time of ALND reduces BCRL and improves patient-reported outcomes compared with ALND alone.

Methods

• Design and setting: Single-center retrospective cohort, 2016–2022.

• Level of evidence: III (retrospective comparative cohort).

• Participants: 187 consecutive breast cancer patients undergoing ALND; 121 received LyMPHA and 66 underwent ALND only. Mean age 56.4 ± 13.6 years.

• Inclusion/exclusion: Patients undergoing ALND with or without LyMPHA.

  • Control arm also included cases where LyMPHA was attempted but not feasible (no suitable lymphatic/venous targets or intraoperative instability).

• Intervention: LyMPHA (immediate lymphatic reconstruction) performed after ALND, anastomosing identified arm-draining lymphatics to venous outflow.

  • Intussusception of lymphatic(s) into into a venule, typically a side branch of thoracodorsal.

  • Technique: U-stitch to intussuscept 1–3 lymphatics into the same venule using 8-0/9-0 nylon.

  • Patency confirmation intraoperatively with indocyanine green (ICG) or fluorescein dye transit.

• Comparator: ALND alone without lymphatic reconstruction.

• Primary endpoint: Time to development of BCRL up to 4 years.

  • BCRL defined as symptomatic arm lymphedema (visible swelling, tightness, heaviness/fullness, pain, impaired limb function) documented at follow-up 12–48 months post-op; counted positive only if symptoms persisted ≥12 months after ALND and required complete decongestive therapy (consensus definition).

• Secondary endpoints: Patient-reported outcomes including functional impairment, drain duration, and postoperative complications.

• Statistical approach: Kaplan–Meier analysis with log-rank test; multivariable Cox proportional hazards model adjusting for age, BMI, smoking, and adjuvant therapies.

Results

• Primary outcome (BCRL): LyMPHA associated with lower cumulative BCRL incidence over time (log-rank P = 0.003).

  • Adjusted effect: HR 0.53 (95% CI 0.28–0.98; P = 0.043) favoring LyMPHA.

• Patient-reported function: Median percent functional impairment 4.7% (LyMPHA) vs 11.6% (ALND-only); P = 0.045.

• Perioperative course: Drain duration median 13 vs 15 days (LyMPHA vs control); P = 0.042.

• Safety: Overall complication rates similar between groups (details per manuscript tables); no signal of harm with LyMPHA.

Conclusion

Immediate lymphatic reconstruction (LyMPHA) at ALND reduces the risk of BCRL and improves patient-reported function without increasing complications.

Strengths

• Contemporary comparative cohort focused specifically on ALND patients.

• Time-to-event (KM/Cox) methods quantify prevention beyond incidence.

• Inclusion of patient-centered outcomes (functional impairment).

Limitations

• Retrospective, nonrandomized design introduces potential selection bias and residual confounding.

• Single-center experience may limit generalizability; technique and surveillance protocols vary across institutions.

• Definition of BCRL not based on objective measurements.

Clinical relevance

For patients undergoing ALND, offering immediate lymphatic reconstruction is reasonable as it may reduce rates of BRCL by as much as half and does not increase complications. Combine ILR with structured postoperative surveillance and early conservative therapy to maximize prevention.

Critiques/Questions

1. What precise diagnostic thresholds and surveillance cadence defined incident BCRL, and were evaluators blinded to ILR status?

2. How did regional nodal irradiation (fields, dose, timing) modify BCRL risk within each arm?

3. What proportion of ALND cases lacked suitable lymphatic or venous targets for ILR, and how were these managed?

4. How many anastomoses were performed on average? Did the number of bypasses correlate with outcomes? What occurred if intraoperative patency could not be demonstrated after anastomosis?

5. What was the added operative time (and resource utilization) for LyMPHA?