Immediate Lymphatic Reconstruction: Lessons Learned Over Eight Years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach to reduce the risk of developing secondary lymphedema and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction of breast cancer related lymphedema (BCRL) in New England. Over the course of our experience, we have made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of ICG imaging to identify baseline lymphatic anatomical variation, the utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and the addition of a lower extremity vein graft for mitigation of venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements and deployment of clips for possible future radiation exposure, enables future studies of ILR patient outcomes. In this contribution, we aim to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction of BCRL.