Immediate Lymphatic Reconstruction to Prevent Postmastectomy Lymphedema: A National Analysis of Outcomes and Regional Trends

Clinical Snapshot

Key Findings

• P Value: P = 0.02

• Effect Size: 19% reduction in lymphedema odds (OR 0.81)

• Primary Outcome: Postmastectomy lymphedema syndrome (PMLS)

• Nnt Or Sensitivity: Based on 5-40% baseline incidence, estimated NNT approximately 25-125 patients

• Confidence Interval: Not reported in abstract

Clinical Application

Requires microsurgical expertise and appropriate theatre time; currently performed in only 1.3% of eligible cases Technique applicable in Australian breast cancer centres with plastic surgery support; may require additional training and resources; potential for PBS consideration given preventive benefits Women undergoing mastectomy with axillary lymph node dissection, particularly younger patients with complete mastectomy

Abstract

BACKGROUND: Lymphedema is a chronic disease characterized by swelling, inflammation, adipose deposition, and fibrosis. In the United States, lymphedema occurs most frequently as a sequela of oncologic lymphadenectomy. Axillary lymph node dissection (ALND) for breast cancer has been associated with a 5%-40% incidence of upper limb lymphedema. In immediate lymphatic reconstruction (ILR), surgeons perform lymphovenous anastomosis (LVA) with ALND to prevent the development of future lymphedema. Although early evidence supports a protective effect of ILR, there have been few large-scale studies on the topic. We leveraged a large claims database to better characterize the outcomes of ILR and national trends related to its adoption. METHODS: Adult female patients with breast cancer who underwent axillary lymph node dissection (ALND) between 2007 and 2022 were identified within the Merative MarketScan Research Databases and stratified according to whether they underwent ILR. Adjusted odds of undergoing ILR, both overall and regionally, and of experiencing postmastectomy lymphedema syndrome (PMLS) were calculated. RESULTS: Of all patients undergoing mastectomy and ALND, 1.3% received ILR. ILR was associated with decreased odds of developing PMLS (OR, 0.81; P  = 0.02). The frequency of ILR procedures increased in all regions between 2017 and 2022, most dramatically in the Midwest and East US. More recent surgery year, younger age, complete mastectomy, and delayed ALND elevated the odds of undergoing ILR ( P  ≤ 0.01). CONCLUSIONS: The popularity of ILR has grown rapidly since 2017, with significant regional variability. Patients with breast cancer who undergo ILR at the time of ALND are significantly less likely to develop lymphedema.

References

1. 1.Shah, J. K., Silverstein, M., & Nazerali, R. (2026). Immediate lymphatic reconstruction to prevent postmastectomy lymphedema: A national analysis of outcomes and regional trends. Annals of Plastic Surgery. https://doi.org/10.1097/SAP.0000000000004681