Immediate lymphatic reconstruction for the prevention of breast cancer-related lymphedema: an experience highlighting the importance of lymphatic anatomy

Immediate lymphatic reconstruction (ILR) has become increasingly utilized for the prevention of breast cancerrelated lymphedema (BCRL). A growing body of evidence has demonstrated the long-term efficacy of ILR in reducing the rate of BCRL. While certain risk factors for BCRL are well -recognized, such as axillary lymph node dissection, regional lymph node radiation, and elevated body mass index, other potential risk factors such as age and taxane-based chemotherapeutics remain under discussion. Our experience with ILR has highlighted an additional potential risk factor for BCRL. Lymphatic anatomy, specifically compensatory lymphatic channels that bypass the axilla, may play a largely underrecognized role in determining which patients will develop BCRL after ILR. Foundational anatomic knowledge has primarily been based on cadaveric studies that predate the twentieth century. Modern approaches to lymphatic anatomical mapping using indocyanine green lymphography have helped to elucidate baseline lymphatic anatomy and compensatory channels, and certain variations within these channels may act as anatomic risk factors. Therefore, the purpose of this review was to highlight ways in which variations in lymphatic anatomy can inform the application and improve the accessibility of this procedure. As ILR continues to advance and evolve, anatomical mapping of the lymphatic system is valuable to both the patient and lymphatic microsurgeon and is a critical area of future study.