Incorporating Lymphedema Reconstruction into Breast Reconstruction: Concepts, Approach, and Systematic Review

Breast cancer-related lymphedema (BCRL) remains a common and morbid consequence of axillary lymph node dissection (ALND) and radiotherapy (RT). As reconstructive microsurgery has advanced, there is increasing interest in integrating lymphatic surgery into breast cancer pathways-both as primary prevention at the time of ALND and as secondary treatment combined with breast reconstruction. We performed a systematic review to synthesize current concepts, techniques, and evidence supporting integrated breast and lymphatic reconstruction. PubMed and Web of Science were searched from inception to December 27, 2025. Eligible studies included breast cancer patients undergoing lymphatic surgery in preventive and/or therapeutic settings (e.g., vascularized lymph node transfer [VLNT] integrated into breast reconstruction). A total of 89 studies met inclusion criteria, encompassing randomized and prospective comparative studies, retrospective cohorts, health services analyses, technical reports, and case series. Two dominant integration paradigms emerged. Preventive integration most commonly involved immediate lymphatic reconstruction (ILR)/lymphatic microsurgical preventive healing approach (LYMPHA) performed at ALND, with reported feasibility and evolving evidence on risk reduction, learning curve, and technical refinements (mapping strategies, recipient vein selection, coupler-assisted techniques, and vein graft use). Staged pathways-including delayed ALND-can still accommodate ILR when suitable lymphatics and recipient veins remain identifiable. Therapeutic integration primarily comprised VLNT incorporated into autologous breast reconstruction (often DIEP-based) and popularized within the concept of total breast anatomy restoration (TBAR), with generally favorable reports on limb volume, cellulitis burden, and quality of life, albeit largely observational. Emerging omental strategies suggest a potential role for preventive VLNT but remain in early stage. Implementation studies highlight access barriers, and economic analyses suggest ILR may be cost-effective in select high-risk populations. BCRL management is evolving toward integrated, continuum-based intervention through preventive ILR and reconstructive VLNT/TBAR strategies. Standardized outcome definitions, longer follow-up-particularly accounting for RT-and implementation-focused research are required to optimize patient selection and enable scalable, equitable adoption.