Penha, T. R., Ijsbrandy, C., Hendrix, N. A., Heuts, E. M., Voogd, A. C., von Meyenfeldt, M. F., & van der Hulst, R. R. (2013). Microsurgical techniques for the treatment of breast cancer-related lymphedema: A systematic review. Journal of Reconstructive Microsurgery, 29(2), 99–106.

To summarize available literature on lymphatic microsurgery for breast cancer-related lymphedema

• Databases searched were PubMed and MEDLINE (2000–2012).
• Search keywords were lymphedema, microsurgery, surgical treatment, breast cancer, lymph node transfer, lymphovenous anastomosis, and lymph vessel transplantation.
• Studies were included in the review if they involved breast cancer treatment examining the effectiveness of microsurgical intervention.
• Studies were excluded if they involved primary lymphedema, lower extremity lymphedema, or mixed upper and lower extremity lymphedema.

• The total number of references retrieved were not reported.
• The checklist from the American Society of Plastic Surgery for therapeutic studies was used for quality assessment.

• The final number of studies included was 19 case reports involving a total of 191 patients.
• The sample range across all studies was 6–127.
• All patients had a breast cancer diagnosis.

Patients were undergoing the active antitumor treatment phase of care.

• Four retrospective case series (n = 52) reported results of composite tissue transfer. Findings were rate of reduction in circumference, reduction in pain, reduced incidence of cellulitis, and improvement in quantitative lymph flow.
• Two studies (n = 139) reported on lymph vessel transplantation. Outcomes included volume reduction and a case of donor site edema.
• Four prospective case series evaluated microsurgery. Findings from these studies were mixed. Studies differed in terms of including patients with early nonfibrotic lymphedema or chronic lymphedema. A number of significant methodological limitations in the evidence were reviewed. 
• Derivative microsurgery was associated with relief of neuropathic pain in two studies for 50%–100% of patients. 
• Three studies of inguinal lymph node transfer reported discontinuation of postoperative conservative therapy of variable rates for 3–24 months. Results were better with shorter duration of lymphedema. Minimal adverse effects were reported overall.

Very limited evidence exists regarding the efficacy of microsurgical techniques for the prevention and management of upper extremity lymphedema in patients with breast cancer who had axillary lymph node excision. The best findings were seen with inguinal lymph node transfer. Consistent positive findings and minimal reported adverse effects were reported. However, high quality-evidence is lacking.

Findings are limited because of the low number of studies, small samples, and lack of high-quality research. Additionally, follow-up duration varied, and most studies did not report rates related to the ability to discontinue conservative management for lymphedema.

Microsurgical techniques for the prevention of lymphedema are promising; however, further high-quality research studies with long-term follow-up are needed.