Alexander Michael Bogdan

Background: Breast cancer-related lymphedema (BCRL) is a chronic complication of axillary surgery and radiation that can lead to persistent swelling, fibrofatty change, recurrent cellulitis, heaviness, and loss of function. Vascularized lymph node transfer (VLNT) is used in patients with more advanced disease, especially when conservative treatment has failed. In breast reconstruction, an important question is whether dual-site VLNT provides enough added benefit to justify the extra operative complexity, or whether single-site transfer remains the better choice for most patients.¹⁻³

Methods: A focused literature review was performed using Google Scholar and the TAMU Medical Sciences Library database. Search terms included breast cancer-related lymphedema, vascularized lymph node transfer, dual recipient site, single recipient site, vascularized omentum lymphatic transplant, reverse lymphatic mapping, indocyanine green lymphography, and VEGF-C. Priority was given to comparative studies, prospective outcome studies, donor-site safety studies, feasibility reports, and translational investigations relevant to breast reconstruction.¹⁻⁸

Results: Available literature suggests that dual-site VLNT tends to show better outcomes than proximal-only or distal-only placement in several areas, including limb-volume reduction, circumference reduction, compression discontinuation, cellulitis reduction, and patient satisfaction, although these differences have not consistently reached statistical significance.¹ Elia et al also reported somewhat better circumference reduction and LYMQoL outcomes with double gastroepiploic VLNT than with single inset, though that study was not limited to postmastectomy upper-extremity disease.² Brown et al showed prospectively that success after VLNT should not be judged by limb size alone, since patients may also improve in bioimpedance, cellulitis burden, compression dependence, and quality of life.³ Feasibility studies support double vascularized omentum lymphatic transplant in patients with more diffuse disease rather than suggesting that dual-site transfer is automatically preferable in all cases.⁴ Donor-site studies further show that reverse lymphatic mapping and dual-tracer fluorescence guidance can reduce iatrogenic donor-site morbidity, while ICG lymphography remains useful for diagnosis, staging, and operative planning.⁵⁻⁷ Early translational work has also examined adenoviral VEGF-C in combination with VLNT, raising the possibility that future lymphatic reconstruction may be augmented biologically as well as surgically.⁸

Conclusions: Dual-site VLNT should be thought of as a selective strategy rather than a routine upgrade over single-site transfer. Current evidence supports tailoring the procedure to disease distribution, scar burden, prior radiation, donor-site risk, and operative goals. Further prospective BCRL-specific studies with standardized outcomes are needed to clarify when the extra complexity of dual-site transfer is truly worthwhile.¹⁻⁸

Works Cited

1. Senger J-LB, Rajaii R, Slater C, Cho M-J. Proximal vs. Recipient Site for Vascular Lymph Node Transfers for Breast Cancer-Related Lymphedema: A Meta-Analysis and Systematic Review. J Clin Med. 2025;14(20):7281. doi:10.3390/jcm14207281.
2. Elia R, Chen HC, Di Taranto G, et al. Gastroepiploic vascularized lymph node transfer for extremities’ lymphedema: is two better than one? A retrospective case-control study. J Plast Reconstr Aesthet Surg. 2022;75(9):3129-3137. doi:10.1016/j.bjps.2022.04.105.
3. Brown S, Mehrara BJ, Coriddi M, et al. A prospective study on the safety and efficacy of vascularized lymph node transplant. Ann Surg. 2022;276(4):635-653. doi:10.1097/SLA.0000000000005591.
4. Kenworthy EO, Nelson JA, Verma R, et al. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol. 2018;117(7):1413-1419. doi:10.1002/jso.25033.
5. Pajula S, Saarikko A, Suominen S, et al. Donor-site safety in microvascular lymph node transfer for breast cancer-related lymphedema using reverse lymphatic mapping—a prospective study. J Plast Reconstr Aesthet Surg. 2024;98:20-31. doi:10.1016/j.bjps.2024.08.063.
6. Chang IA, Swanson MA, Rajan M, Schwarz GS. Dual fluorescent tracers for surgical guidance: preventing donor-site lymphedema in vascularized lymph node transfer. Plast Reconstr Surg Glob Open. 2022;10(6):e4390. doi:10.1097/GOX.0000000000004390.
7. Chen WF, Qin ES, Bowen MJ, Little AS, Lensing JN. Exercise-enhanced ICG lymphography: a fast approach to diagnosis and staging of lymphedema. Int Microsurg J. 2021;5(1):2. doi:10.24983/scitemed.imj.2021.00140.
8. Rannikko EH, Pajula S, Suominen SH, et al. Phase II study shows the effect of adenoviral vascular endothelial growth factor C and lymph node transfer in lymphedema. Plast Reconstr Surg. 2025;155(2):256e-267e. doi:10.1097/PRS.0000000000011675.