Open AccessSystematic Review One Surgery, Two Solutions: A Systematic Review of Combined Autologous Breast Reconstruction and Lymphatic Surgery by Ion Lingenheil Ion Lingenheil Scilit Preprints.org Google Scholar 1, Lisa Radacher Lisa Radacher Scilit Preprints.org Google Scholar 1, Hans-Günther Machens Hans-Günther Machens Scilit Preprints.org Google Scholar 2, Michael Mayr-Riedler Michael Mayr-Riedler Scilit Preprints.org Google Scholar 1, Katrin Seidenstücker Katrin Seidenstücker Scilit Preprints.org Google Scholar 3, Niclas Peter Broer Niclas Peter Broer Scilit Preprints.org Google Scholar 1,4 and Lisanne Grünherz Lisanne Grünherz Scilit Preprints.org Google Scholar 1,4,* 1 Department of Plastic, Reconstructive, Aesthetic, Hand- and Burn Surgery, Munich Clinic Bogenhausen, 81925 Munich, Germany 2 Department of Plastic and Hand Surgery, Klinikum Rechts der Isar, Technical University Munich, 81675 Munich, Germany 3 Department for Plastic and Reconstructive Surgery, Sana Kliniken Düsseldorf, 40625 Düsseldorf, Germany 4 School of Medicine and Health, Technical University Munich, 81675 Munich, Germany * Author to whom correspondence should be addressed. Curr. Oncol. 2026, 33(6), 338; https://doi.org/10.3390/curroncol33060338 (registering DOI) Submission received: 30 April 2026 / Revised: 22 May 2026 / Accepted: 2 June 2026 / Published: 6 June 2026 Simple Summary This systematic review looked at a surgical approach that combines breast reconstruction using a patient’s own tissue with procedures to improve lymph fluid drainage after breast cancer treatment. It included 27 studies, with 499 patients followed for about two years. The most common method used tissue from the lower abdomen along with lymph nodes to rebuild the breast and help reduce swelling in the arm. Overall, patients showed reduced arm swelling, fewer infections and improved quality of life. Complications were uncommon, with small fluid collections occurring in a few cases and very rare loss of the reconstructed tissue. In general, combining these procedures appears to be a safe and effective option, although more consistent and long-term research is still needed. Abstract Simultaneous autologous breast reconstruction (ABR) and lymphatic surgery has emerged as a strategy to address breast cancer-related lymphedema (BCRL) while restoring breast contour within a single operative procedure. In light of the diversity of surgical strategies, we aimed to evaluate the current literature on combined ABR and lymphatic surgery, with particular focus on surgical techniques, clinical outcomes, complications, and patient-reported satisfaction. A systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD420251135446). Medline, Embase, CENTRAL, Web of Science, and PubMed were searched through 9 January 2026 Studies reporting outcomes of simultaneous ABR and lymphatic reconstruction were included. Data on surgical techniques, complications, changes in limb volume and cellulitis incidence, and patient-reported outcomes were extracted. Twenty-seven studies including 499 patients (mean follow-up 23 months) were analyzed. The most common approach was a chimeric deep inferior epigastric perforator (DIEP) flap with inguinal lymph nodes (459 patients), followed by ABR with a separate vascularized lymph node transfer and ABR with lymphovenous anastomosis. Most studies reported postoperative reductions in limb volume and cellulitis, with cellulitis reduction rates up to 100%. Patient-reported outcomes (LYMQOL, ULL-27, LYMPH-Q) showed improved quality of life. Complication rates were low, including 4% seroma and 1% flap loss after chimeric DIEP. Simultaneous ABR and lymphatic reconstruction is feasible and associated with improved clinical and patient-reported outcomes. However, heterogeneity limits comparison between the different surgical techniques, and prospective studies with standardized outcomes measurements are needed. 1. Introduction Autologous breast reconstruction (ABR) and lymphatic surgeries, such as lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), have emerged as effective procedures to address both the physical and psychological sequelae of breast cancer treatment. In recent years, there has been growing interest in combining ABR with lymphatic surgery in a single operative session, aiming to restore breast contour while simultaneously treating or preventing breast cancer-related lymphedema (BCRL) [ 1, 2]. Despite an increasing number of reports describing this combined approach, the comparative effectiveness, safety, and long-term outcomes of the different surgical techniques and combinations have not been systematically synthesized. 2. Materials and Methods We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A review protocol was designed and registered on PROSPERO, the international prospective register of systematic reviews (Registration number: CRD420251135446). A comprehensive literature search was conducted on 9 January 2026, across multiple databases, including Medline, Embase, Central Cochrane, Web of science and PubMed. Language was restricted to English and German. There was no time restriction. The search strategy employed a combination of controlled vocabulary terms and free-text terms, which were adapted for each database. Details of the individual search equations for all databases are provided as Supplementary Table S1. The resulting records were imported into Rayyan, where duplicates were removed. Two authors (IL, LG) independently screened the titles and abstracts of the retrieved studies. Discrepancies were resolved by a third reviewer (LR). Full-text articles of potentially relevant studies were then reviewed for eligibility, with all disagreements ultimately resolved by consensus among the three reviewers. Inclusion criteria were limited to randomized controlled trials, prospective cohort studies, retrospective cohort studies, cross-sectional studies, case-reports and case series. Patients were required to have undergone simultaneous microvascular breast and lymphatic reconstruction. Systematic reviews, meta-analyses, and publications not written in English were excluded, as well as cadaveric studies and papers introducing novel techniques without defined outcome measurements, e.g., volume measurements. For quantitative analysis the following parameters were extracted: number of patients, age, lymphedema stage, circumference/volume measurements, complications and patient-reported outcome measurements. When studies compared simultaneous breast and lymph reconstruction with other techniques, e.g., lymphatic reconstruction alone, data for the qualifying groups was extracted separately and included in the analysis. The methodological quality of the included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) instrument. Additionally, the completed PRISMA checklist is provided as Supplementary Material File S1 [ 14]. 3. Results The systematic search yielded 637 articles after removal of duplicates. Following review of title and abstract, 76 articles were included in full-text review. Based on the inclusion criteria, 27 articles were finally selected. The detailed selection process is shown in Figure 1. Of the 27 included studies, 23 could be evaluated using the MINORS instrument. The remaining studies were excluded from the quality assessment because they were case reports or case series with insufficient methodological information. As most studies did not include a comparative cohort, the 8-item version of the MINORS scale was used. The median score was 6, indicating overall limited methodological quality of the available evidence. ( Supplementary Table S2). Across all studies, 499 patients undergoing simultaneous microvascular breast and lymphatic reconstruction with a mean follow-up of 23 months were analyzed. The mean age at the time of surgery was 51 years. Most patients were diagnosed with lymphedema stage 2 according to the staging of the International Society of Lymphology (ISL) while only a very small proportion of patients received prophylactic lymphatic reconstruction after axillary lymph node dissection. We identified the following combinations of surgical therapy: Chimeric deep inferior epigastric perforator (DIEP) with inguinal lymph nodes, ABR and VLNT as separate flaps and ABR combined with LVAs. 3.1. Chimeric Deep Inferior Epigastric Perforator Flap with Inguinal Lymph Nodes Most authors base their flap design on preoperative computed tomography angiography. In addition, in the majority of studies preoperative lymphoscintigraphy and intraoperative reverse lymph node mapping was performed to identify and spare sentinel lymph nodes in the groin. While the DIEP flap was anastomosed to the internal mammary vessels in most of the studies with a few exceptions with anatomosis to the thoracodorsal vessles, there was considerable heterogenity with regard to the revascularization of the lymph node flap at the axilla. In six studies, both the arterial and venous pedicles were anastomosed to the thoracodorsal vessels or to branches of the serratus or lateral thoracic wall. The remaining authors performed either venous supercharging alone or no additional arterial or venous anastomoses when the lymph node flap demonstrated adequate perfusion [ 31]. Based on seven studies the mean postoperative reduction in cellulitis episodes is 84% (range: 50–100%). While 14 out of 21 studies reported postoperative improvements in arm volume, there was considerable heterogeneity in the methods used to assess volume and circumference, limiting the comparability of results across studies. 3.2. Autologous Breast Reconstruction and Separate Vascularized Lymph Node Transfer Based on two retrospective studies, Dionyssiou described a pedicled, fat-augmented latissimus dorsi flap combined with simultaneous VLNT as an alternative for thin, nulliparous patients. In this technique, lymph nodes were harvested either from the ipsilateral lateral thoracic wall or from the groin and revascularized to the lateral thoracic or serratus anterior vessels [ 15, 17]. 3.3. Autologous Breast Reconstruction and Lymphovenous Anastomosis We identified only one study [ 38] that performed ABR based on DIEP or PAP flap with simulatenous LVAs of the affected arm ( Figure 4). Analogous to the publications mentioned above, LVAs were created following prior intraoperative lymphography in four patients with lymphedema grade I and II according to the Cheng classification. Based on the comparison of the postoperative circumference reduction rate, the authors demonstrate that ABR and LVAs resulted in less volume reduction than ABR combined with VLNT. 3.4. Complications For the quantitative analysis of complications, eleven studies on chimeric DIEP flaps with inguinal lymph nodes and six studies on ABR with separate VLNT were included. Wound complications were the most common adverse events in both groups ( Figure 5). Seroma at the lymph node harvest site occurred in 4% of chimeric DIEP cases, and flap loss in 1%. No donor-site lymphedema was reported in either group. 3.5. Patient-Reported Outcome Measurements Overall, five studies included one of the following Patient-reported outcome measurements (PROMS) that have been well validated for arm lymphedema: ULL-27, LYMPH-Q and LYMQOL. All of these studies evaluated patients who underwent a chimeric DIEP flap combined with inguinal lymph nodes and could demonstrate significant improvements in different domains of quality of life. Briefly, the ULL-27 was used in two studies comprising a total of 70 patients, in which significant improvements were observed across the physical, psychological, and social domains. The LYMQOL was assessed in three studies, comprising a total of 66 patients, demonstrating significant improvements across all domains, including appearance, function, symptoms, mood, and overall score. Myung et al. evaluated the LYMPH-Q in a cohort of 23 patients who underwent a muscle-sparing TRAM flap with simultaneous VLNT. The LYMPH-Q comprises six distinct domains; however, instead of reporting each domain separately, the authors calculated a composite mean score across all domains. This averaged score showed significant improvements at 12 months postoperatively, indicating an overall enhancement in quality of life. 4. Discussion This systematic review demonstrates that simultaneous microvascular breast and lymphatic reconstruction is a feasible and increasingly utilized approach for the management of breast cancer-related lymphedema, with a growing body of evidence supporting its effectiveness. Across the included studies, most patients underwent chimeric DIEP flap reconstruction incorporating inguinal lymph nodes, whereas alternative strategies, including microvascular ABR with simultaneous VLNT or combined with LVAs, were less frequently reported. The available data confirm postoperative improvements in arm volume, reductions in cellulitis rates and patient-reported quality of life. With regard to volume and circumference measurements all studies reported on postoperative improvements. Due to a high heterogeneity across studies a more detailed quantitative analysis regarding extremity volume in relation to different surgical techniques, was not feasible. Therefore, conclusions can only be drawn based on the frequency of reported approaches in the literature. Most authors reported the use of a chimeric DIEP flap combined with inguinal lymph nodes, which offers the advantage of a single donor site and a single microsurgical flap harvest. This approach may reduce operative complexity and shorten surgical time, particularly when compared with techniques requiring the harvest of a second flap for lymphatic reconstruction. Interestingly, we observed considerable heterogeneity in the revascularization strategies of the lymph node component. While the DIEP flap itself was consistently anastomosed to the internal mammary vessels, management of the lymph node flap varied substantially, ranging from complete arterial and venous revascularization to venous supercharging alone, or even omission of additional microvascular anastomoses when flap perfusion appeared clinically adequate. Although this aspect has not yet been systematically analyzed, such variability may have important implications for outcomes following lymphatic reconstruction. Complete arterial and venous revascularization of the lymph node flap may theoretically optimize tissue perfusion, lymphangiogenesis, and the long-term viability of transferred lymphatic tissue. Adequate arterial inflow may be particularly important for maintaining the metabolic activity of transferred lymph nodes and supporting the release of lymphangiogenic growth factors, such as vascular endothelial growth factor-C, which are believed to promote regeneration of lymphatic channels [ 40]. Similarly, the importance of sufficient venous drainage in VLNT has increasingly been emphasized in the literature. Ciudad et al. described venous hypertension as a potential limitation of vascularized lymph node flaps and proposed venous supercharging to optimize flap hemodynamics and reduce inflow–outflow mismatch [ 41]. Furthermore, given that lymphatic fluid is ultimately transferred into the venous circulation through intrinsic lymphovenous communications, optimization of venous outflow may not only improve flap perfusion but also directly enhance the functional efficacy of lymphatic reconstruction [ 42]. These considerations may explain why some authors attribute increased emphasis to an additional venous anastomosis of the included lymph node flap. The rate of seroma formation following chimeric DIEP with inguinal lymph nodes was notably low, particularly given that groin lymph node harvest is associated with a seroma risk of up to 60% [ 45, 46], while DIEP flap harvest itself carries a reported incidence of up to 48% [ 47]. This finding is likely attributable to the adoption of refined surgical techniques aimed at minimizing seroma formation, including progressive tension sutures, meticulous ligation of lymphatic vessels, and reduction in dead space in the groin [ 46]. Additionally, some surgeons preserve extra subcutaneous tissue on the superior skin flap at the level of lymph node harvest site [ 25, 28]. During abdominal closure, this tissue is transposed to fill the resulting defect in the groin, thereby reducing dead space and potentially lowering the risk of postoperative fluid accumulation. This systematic review is limited by the substantial heterogeneity among the included studies, which restricts direct comparability and precludes further quantitative analysis. Differences in surgical techniques, adjunctive procedures, outcome measurements, and follow-up protocols contributed to considerable variability across studies. In addition, most studies were retrospective in design, of low methodological quality, and involved relatively small patient cohorts, increasing the risk of selection and reporting bias. Several studies also originated from the same author groups, raising the possibility of partially or completely overlapping patient populations. The results of the quality assessment have now been added to the manuscript and are presented in Supplementary Table S2. We also acknowledge in the discussion that the predominance of retrospective and non-comparative studies limits the strength of the conclusions that can be drawn. 5. Conclusions In conclusion, simultaneous ABR with lymphatic reconstruction represents a feasible and increasingly applied surgical strategy for BCRL, with consistent improvements in limb volume, cellulitis incidence, and patient-reported outcomes. However, substantial heterogeneity in study design, outcome reporting, and surgical techniques limits direct comparability and precludes further quantitative synthesis. While most surgeons support the use of chimeric DIEP flaps incorporating inguinal lymph nodes, the optimal surgical strategy and the underlying mechanisms governing lymphatic function and arm drainage after transfer remain incompletely understood. Further prospective studies with objective lymphatic imaging and long-term follow-up are required to refine surgical techniques and clarify the mechanism of lymphatic integration. Supplementary Materials The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/curroncol33060338/s1, Supplementary Table S1: Search equations for all databases; Supplementary Table S2: MINORS score; File S1: PRISMA 2020 Checklist. Reference [ 14] has been cited in Supplementary Materials. Author Contributions Conceptualization, I.L., L.R., M.M.-R., N.P.B., K.S., H.-G.M. and L.G.; methodology, I.L., L.R. and L.G.; validation, I.L., L.R. and L.G.; formal analysis, I.L., L.R. and L.G.; writing—original draft preparation, I.L. and L.G.; writing—review and editing, I.L., L.R., M.M.-R., N.P.B., K.S., H.-G.M. and L.G.; visualization, L.G.; supervision, M.M.-R., N.P.B., K.S., H.-G.M. and L.G.; All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Institutional Review Board Statement Not applicable. Informed Consent Statement Not applicable. Data Availability Statement No new data were created or analyzed in this study. Data sharing is not applicable to this article. Acknowledgments Conflicts of Interest The authors declare no conflicts of interest. Abbreviations The following abbreviations are used in this manuscript: PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis ABR Autologous breast reconstruction BCRL Breast cancer related lymphedema VLNT vascularized lymph node transfer GE-VLNT gastroepiploic vascularized lymph node transfer LVA lymphovenous anastomosis DIEP deep inferior epigastric perforator MSTRAM muscle sparing transverse rectus abdominis muscle ULL-27 Upper Limb Lymphedema 27 LYMQOL Lymphedema Quality of Life Questionnaire QOL quality of life PROMs patient reported outcome measurements ISL International society of lymphology TDA thoracodorsal artery TDV thoracodorsal vein IMV internal mammary vein LTA lateral thoracic artery LTV lateral thoracic vein URV ulnar recurrent artery and vena commitantes RA radial artery and vena commitantes SBA arterial branch to serratus SBV venous branch to serratus NA not available References Winters, H.; Tielemans, H.J.P.; Hummelink, S.; Slater, N.J.; Ulrich, D.J.O. 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A chimeric DIEP flap is harvested together with inguinal lymph nodes based on the superficial inferior epigastric or superficial circumflex iliac vessels. The inferior epigastric artery and vein are then anastomosed to the internal mammary vessels. An additional arterial and venous anastomosis may be performed between the pedicle supplying the lymph nodes and the thoracodorsal vessels. The affected arm may be further treated with lymphovenous anastomosis. Figure 2. A chimeric DIEP flap is harvested together with inguinal lymph nodes based on the superficial inferior epigastric or superficial circumflex iliac vessels. The inferior epigastric artery and vein are then anastomosed to the internal mammary vessels. An additional arterial and venous anastomosis may be performed between the pedicle supplying the lymph nodes and the thoracodorsal vessels. The affected arm may be further treated with lymphovenous anastomosis. Figure 3. A DIEP flap is harvested and anastomosed to the internal mammary vessels. During the same procedure, a gastroepiploic lymph node flap is harvested laparoscopically and anastomosed to the thoracodorsal vessels at the axilla. The affected arm may additionally undergo lymphovenous anastomosis to further enhance lymphatic drainage. Figure 3. A DIEP flap is harvested and anastomosed to the internal mammary vessels. During the same procedure, a gastroepiploic lymph node flap is harvested laparoscopically and anastomosed to the thoracodorsal vessels at the axilla. The affected arm may additionally undergo lymphovenous anastomosis to further enhance lymphatic drainage. Figure 4. A DIEP flap is harvested and microsurgically anastomosed to the internal mammary vessels. Concurrently, lymphovenous anastomoses are performed in the affected arm to enhance lymphatic drainage. Figure 4. A DIEP flap is harvested and microsurgically anastomosed to the internal mammary vessels. Concurrently, lymphovenous anastomoses are performed in the affected arm to enhance lymphatic drainage. Figure 5. Bar chart showing the distribution of complications after chimeric DIEP flap with inguinal lymph nodes compared with autologous breast reconstruction (ABR) with a separate vascularized lymph node transfer (VLNT). Figure 5. Bar chart showing the distribution of complications after chimeric DIEP flap with inguinal lymph nodes compared with autologous breast reconstruction (ABR) with a separate vascularized lymph node transfer (VLNT). Table 1. Studies on chimeric DIEP flap with inguinal lymph nodes. Table 1. Studies on chimeric DIEP flap with inguinal lymph nodes. Author (Year) Study Design N ISL Stage (N) Recipient Vessels VLNT Additional LVA Mean (N) Outcome Lymphedema (Volume/Circumference) Cellulitis Reduction % QOL Instrument NA—not available; VLNT—vascularized lymph node transfer; LVA—lymphovenous anastomosis; TDA—thoracodorsal artery; TDV—thoracodorsal vein; IMV—internal mammary vein; LTA—lateral thoracic artery; LTV—lateral thoracic vein; URV—ulnar recurrent artery and vena commitantes; RA—radial artery and vena commitantes; SBA—arterial branch to serratus; SBV—venous branch to serratus. # Number in brackets refers to the total study population; only a subgroup received the combined approach analyzed. Table 2. Studies on autologous breast reconstruction and separate vascularized lymph node transfer. Table 2. Studies on autologous breast reconstruction and separate vascularized lymph node transfer. Author (Year) Study Design N ISL Stage (N) Surgical Technique Recipient Vessels VLNT Outcome Cellulitis Reduction Rate NA—not available; DIEP—deep inferior epigastric perforator flap; GE-VLNT—gastroepiploic vascularized lymph node transfer; VLNT—vascularized lymph node transfer; LT—latissimus dorsi; LTA—lateral thoracic artery; LTV—lateral thoracic vein; URV—ulnar recurrent artery and vena commitantes; RA—radial artery and vena commitantes; SBA—arterial branch to serratus; SBV—venous branch to serratus. # Number in brackets refers to the total study population; only a subgroup received the combined approach analyzed. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. © 2026 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. Share and Cite MDPI and ACS Style Lingenheil, I.; Radacher, L.; Machens, H.-G.; Mayr-Riedler, M.; Seidenstücker, K.; Broer, N.P.; Grünherz, L. One Surgery, Two Solutions: A Systematic Review of Combined Autologous Breast Reconstruction and Lymphatic Surgery. Curr. Oncol. 2026, 33, 338. https://doi.org/10.3390/curroncol33060338 AMA Style Lingenheil I, Radacher L, Machens H-G, Mayr-Riedler M, Seidenstücker K, Broer NP, Grünherz L. One Surgery, Two Solutions: A Systematic Review of Combined Autologous Breast Reconstruction and Lymphatic Surgery. Current Oncology. 2026; 33(6):338. https://doi.org/10.3390/curroncol33060338 Chicago/Turabian Style Lingenheil, Ion, Lisa Radacher, Hans-Günther Machens, Michael Mayr-Riedler, Katrin Seidenstücker, Niclas Peter Broer, and Lisanne Grünherz. 2026. "One Surgery, Two Solutions: A Systematic Review of Combined Autologous Breast Reconstruction and Lymphatic Surgery" Current Oncology 33, no. 6: 338. https://doi.org/10.3390/curroncol33060338 APA Style Lingenheil, I., Radacher, L., Machens, H.-G., Mayr-Riedler, M., Seidenstücker, K., Broer, N. P., & Grünherz, L. (2026). One Surgery, Two Solutions: A Systematic Review of Combined Autologous Breast Reconstruction and Lymphatic Surgery. Current Oncology, 33(6), 338. https://doi.org/10.3390/curroncol33060338 Article Metrics Article metric data becomes available approximately 24 hours after publication online.
