Min-Jeong Cho

Breast reconstruction after mastectomy or breast-conserving surgery requires careful planning that accounts for patient preference, comorbidities, tumor characteristics, and anticipated neoadjuvant or adjuvant therapies. Advances in the treatment of breast cancer have led to evolving recommendations for these therapies, with each influencing not just the complications from surgery but also the long-term outcomes. This narrative review summarizes the current indications for these therapies and their potential impacts on breast reconstruction. Contemporary recommendations for postmastectomy radiation therapy, chemotherapy, immunotherapy, endocrine therapy, and other targeted therapies are explored, with an emphasis placed on perioperative management of systemic therapies and how they may influence reconstructive decision-making. Understanding the nuances of these therapies enables plastic surgeons to be strategic in the timing of reconstruction through individualized planning and can improve reconstructive success. As breast cancer treatment evolves, familiarity with oncologic management is essential for achieving safe, patient-centered care.

Background: Breast cancer–related lymphedema (BCRL) is a common and debilitating complication of axillary lymph node dissection (ALND), affecting approximately 1 in 5 patients. While preventive lymphatic surgeries such as prophylactic lymphovenous bypass (pLVB) performed at the time of ALND have been shown to decrease the risk of developing BCRL, success is frequently limited by inadequate recipient veins within the axilla. In this study, we report our experience with utilizing axillary vascular grafts harvested from within the axillary dissection field to perform pLVB in vein-depleted axillae to prevent the development of BCRL in patients undergoing ALND. Methods: A retrospective review was performed of breast cancer patients undergoing ALND with planned pLVB at a single institution. Patients in whom axillary vascular grafts were used to enable lymphatic reconstruction were included. Demographic, oncologic, operative, and graft-specific variables were collected. Outcomes included successful lymphatic reconstruction and development of BCRL, assessed using a standardized institutional surveillance protocol incorporating circumferential measurements or perometry. Results: Thirty-two patients had a mean age of 52.3 years (SD, 12.9) and median BMI of 26.9 kg/m ² (IQR, 23.8–28.7), with median follow-up of 15 months (IQR, 11–31). Of the 121 transected lymphatic vessels, interposition grafts were required for 74.8% of reconstructions. A total of 35 grafts (74.3% venous, 25.7% arterial) with median length of 5 cm (IQR, 4–6) were performed with a median of 3 pLVBs (IQR, 2–5) performed per patient. BCRL developed in 6 patients (18.8%) with an average follow-up of 21.3 months (IQR, 11−31); those affected had a higher mean number of lymph nodes removed (22.3 vs. 15.4; P < .05), and as a result, more graft-based pLVBs (median 4.5 vs. 2; P < .05). Conclusion: Axillary-based vascular grafting is a versatile strategy that expands reconstructive capacity during pLVB without additional donor-site morbidity. This approach enables completion of lymphatic reconstruction in anatomically challenging, vein-depleted axillae and represents a practical adjunct for immediate lymphatic reconstruction in high-risk breast cancer patients.

Lymphedema affects over 250 million people worldwide and is increasingly managed with physiologic procedures such as lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT). These supermicrosurgical techniques require advanced training, are ergonomically demanding, and can be limited in anatomically constrained regions. Robotic surgical systems offer high-resolution visualization, motion scaling, tremor reduction, and improved ergonomics, making them promising adjuncts for lymphatic supermicrosurgery. However, evidence on safety, feasibility, and outcomes remains limited. A systematic review was conducted in accordance with PRISMA guidelines using PubMed, Cochrane Library, and Embase from inception through December 2024. Eligible studies included human clinical reports of robotic-assisted peripheral lymphatic reconstruction. Extracted data included demographics, operative details, outcomes, and study quality. Seven studies involving 134 patients and 221 anastomoses were included, of which 78% (172) were performed robotically. The Symani system was most frequently used. Robotic procedures comprised 59.9% LVBs and 32% VLNTs or other free flaps. Across studies, mean anastomotic time was longer with robotic assistance (25.7 minutes) compared with manual techniques (11 minutes); however, three studies demonstrated significant time reduction with experience, ultimately approaching manual times. When reported, clinical outcomes, including limb volume reduction and quality-of-life measures, were comparable between robotic and manual groups. Advantages included tremor elimination and improved ergonomics, while challenges included cost, setup time, and lack of haptic feedback. Robotic-assisted lymphatic supermicrosurgery is safe and feasible, with outcomes comparable to conventional surgery. Continued refinement, cost reduction, and standardized outcome reporting will determine its role in expanding therapeutic and preventive lymphatic reconstruction.

Lymphedema is a chronic, progressive, and debilitating disease of the lymphatic system with no current cure. Physiologic procedures, which address the underlying pathophysiology of lymphatic dysfunction, have gained traction in both treatment and prevention of lymphedema. This narrative review examines current physiologic lymphedema surgical techniques and emerging developments in this rapidly evolving field. While the two most common physiologic surgeries remain lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT), newer physiologic surgery techniques such as vascularized lymph vessel transfer (VLVT) and lymph node to vein anastomosis (LNVA) have been described in an effort to reduce donor site morbidity, with early promising clinical outcomes. The use of bioengineering with stem cells, pro-lymphangiogenic growth factors, and biomaterials such as Biobridge can be applied in conjunction with surgery to help promote lymphangiogenesis. Technological advances in robotic surgical systems and 3D exoscopes are helping to make supermicrosurgery more technically feasible and ergonomic, and increasing accessibility to lymphedema surgery. As our surgical armamentarium expands, treatment algorithms must be updated to determine how various surgical techniques can be combined and sequenced, how the indications for physiologic surgery can be expanded, and how surgical treatment can be tailored to the patient and disease process.

Background/Objectives: Despite the popularity of vascularized lymph node transfers (VLNTs) for treatment of breast cancer-related lymphedema (BCRL), the comparative effectiveness of VLNT placement locations is unknown. In this meta-analysis, we examined the impact of VLNT recipient site (proximal vs. distal vs. dual) and adjunct surgical techniques, including scar release, supercharging, and intervention timing on patient outcomes. Methods: PRISMA-guided search of PubMed, MEDLINE, and Embase (January 2015–March 2025). Patient outcomes including limb circumference/volume reduction, cellulitis frequency, compression garment discontinuation, and patient satisfaction were analyzed. Subgroup analyses assessed node placement, scar release, supercharging, and timing. Results: A total of 1440 patients were analyzed (proximal 63.8%; distal 29.2%; dual 7.0%). No significant differences in mean volume/circumference reductions, patient satisfaction rates, and compression garment discontinuation were observed amongst placement strategies (p > 0.30). Adjunct scar release (65%) was associated with significantly greater patient satisfaction (p = 0.04) and showed trends toward improved volume reduction and compression discontinuation. Earlier intervention (<5 years from diagnosis) showed improved volume reduction, patient satisfaction, and compression discontinuation. Longitudinal analysis revealed dual placement maintained superiority throughout a 12-month follow-up. Conclusions: VLNT is an effective treatment for BCRL regardless of placement location, with all strategies demonstrating substantial clinical improvements. While dual placement showed numerically superior outcomes across all measures, differences did not reach statistical significance due to limited number of studies. Adjunct scar release significantly improves patient satisfaction, and earlier intervention may optimize outcomes. These findings suggest that recipient site selection may be guided by technical factors, vessel availability, and patient preference rather than efficacy differences.

Striving for higher levels of evidence in sensory restoration in DIEP flap breast reconstruction

Background/Objectives: Modern breast reconstruction has undergone substantial evolution, with implant-based, pedicled autologous, and free autologous techniques. The purpose of this study is to review the current state of the art in free autologous breast reconstruction, highlighting advancements in the types of flaps, donor site selection, techniques, and functional restoration. Methods: A literature review was conducted using PubMed to capture studies related to well-known free flaps that are used for breast reconstruction. Studies for each flap type were reviewed and sorted for inclusion into one of six categories: (1) clinical outcomes, (2) comparison studies of alternative flaps, (3) preoperative planning, (4) flap classifications and perfusion zones, (5) technique descriptions, and (6) time and cost analyses. Results: The majority (77%) of articles included were written on various types of abdominally based free flaps, including TRAM, DIEP, and SIEA flaps. These studies indicated an evolution in technique over time to minimize donor site morbidity, improve patient-reported and functional outcomes, improve efficiency, and expand clinical indications. The remaining 23% of articles discussed alternative flap choices, including PAP, TUG, S/IGAP, and LAP flaps. Studies highlighted technical challenges and the evolution of techniques to make these flaps more accessible, as well as how to combine flaps to expand clinical indications. Conclusions: Autologous breast reconstruction has evolved significantly, with advancements in techniques such as robotic-assisted surgery, multi-flap reconstruction, bipedicled flaps, and neurotization. This review highlights the current best practices while acknowledging ongoing challenges and the potential for future innovations in microsurgery, nerve regeneration, and personalized medicine, which hold promise for further refining outcomes.