{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T20:57:36Z","timestamp":1789073856235,"version":"build-2803163510"},"reference-count":52,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T00:00:00Z","timestamp":1760486400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Despite the popularity of vascularized lymph node transfers (VLNTs) for treatment of breast cancer-related lymphedema (BCRL), the comparative effectiveness of VLNT placement locations is unknown. In this meta-analysis, we examined the impact of VLNT recipient site (proximal vs. distal vs. dual) and adjunct surgical techniques, including scar release, supercharging, and intervention timing on patient outcomes. Methods: PRISMA-guided search of PubMed, MEDLINE, and Embase (January 2015\u2013March 2025). Patient outcomes including limb circumference\/volume reduction, cellulitis frequency, compression garment discontinuation, and patient satisfaction were analyzed. Subgroup analyses assessed node placement, scar release, supercharging, and timing. Results: A total of 1440 patients were analyzed (proximal 63.8%; distal 29.2%; dual 7.0%). No significant differences in mean volume\/circumference reductions, patient satisfaction rates, and compression garment discontinuation were observed amongst placement strategies (p &gt; 0.30). Adjunct scar release (65%) was associated with significantly greater patient satisfaction (p = 0.04) and showed trends toward improved volume reduction and compression discontinuation. Earlier intervention (&lt;5 years from diagnosis) showed improved volume reduction, patient satisfaction, and compression discontinuation. Longitudinal analysis revealed dual placement maintained superiority throughout a 12-month follow-up. Conclusions: VLNT is an effective treatment for BCRL regardless of placement location, with all strategies demonstrating substantial clinical improvements. While dual placement showed numerically superior outcomes across all measures, differences did not reach statistical significance due to limited number of studies. Adjunct scar release significantly improves patient satisfaction, and earlier intervention may optimize outcomes. These findings suggest that recipient site selection may be guided by technical factors, vessel availability, and patient preference rather than efficacy differences.<\/jats:p>","DOI":"10.3390\/jcm14207281","type":"journal-article","created":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T14:04:02Z","timestamp":1760537042000},"page":"7281","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Proximal vs. Recipient Site for Vascular Lymph Node Transfers for Breast Cancer-Related Lymphedema: A Meta-Analysis and Systematic Review"],"prefix":"10.3390","volume":"14","author":[{"given":"Jenna-Lynn B.","family":"Senger","sequence":"first","affiliation":[{"name":"Division of Plastic Surgery, Vancouver Coastal Health, Vancouver General Hospital, 1788-1111 West Georgia Street, Vancouver, BC V6E 4M3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-5517-6701","authenticated-orcid":false,"given":"Ramin","family":"Rajaii","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, 2nd Floor Suite 2140, Columbus, OH 43212, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-0661-1706","authenticated-orcid":false,"given":"Christopher","family":"Slater","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, 2nd Floor Suite 2140, Columbus, OH 43212, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3517-1523","authenticated-orcid":false,"given":"Min-Jeong","family":"Cho","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, 2nd Floor Suite 2140, Columbus, OH 43212, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"573","DOI":"10.1097\/SAP.0000000000000513","article-title":"Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema","volume":"74","author":"Akita","year":"2015","journal-title":"Ann. Plast. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1016\/S1470-2045(13)70076-7","article-title":"Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis","volume":"14","author":"DiSipio","year":"2013","journal-title":"Lancet Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Cho, M.-J., Flores Garcia, J., Myung, Y., Cha, H.G., Hayashi, A., Hong, J.P., and Skoracki, R. (2024). Evolving Role of Lymphedema Surgery on Breast Reconstruction: A Systematic Review and Multi-Institutional Algorithmic Approach. J. Clin. Med., 13.","DOI":"10.3390\/jcm13216518"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2007","DOI":"10.1245\/s10434-024-16640-8","article-title":"Preventing Breast Cancer-Related Lymphedema: A Comprehensive Analysis of a 9-Year Single-Center Experience of Prophylactic Lymphovenous Bypass","volume":"32","author":"Cho","year":"2025","journal-title":"Ann. Surg. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1055\/s-0037-1603738","article-title":"Contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator flap to the efficacy of vascularized lymph node transfer in patients with breast cancer-related lymphedema","volume":"33","author":"Akita","year":"2017","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e2149","DOI":"10.1097\/GOX.0000000000002149","article-title":"Dorsal wrist placement for vascularized submental lymph node transfer significantly improves breast cancer-related lymphedema","volume":"7","author":"Aljaaly","year":"2019","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1055\/s-0034-1381957","article-title":"From theory to evidence: Long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers","volume":"31","author":"Patel","year":"2015","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1055\/s-0035-1549133","article-title":"Noncontrast Magnetic Resonance Lymphography","volume":"32","author":"Derhy","year":"2016","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1002\/micr.30168","article-title":"Double gastroepiploic vascularized lymph node transfers to middle and distal limb for the treatment of lymphedema","volume":"37","author":"Ciudad","year":"2017","journal-title":"Microsurgery"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"512","DOI":"10.21037\/gs.2020.01.14","article-title":"Combined microvascular breast and lymphatic reconstruction with deep inferior epigastric perforator flap and gastroepiploic vascularized lymph node transfer for postmastectomy lymphedema patients","volume":"9","author":"Ciudad","year":"2020","journal-title":"Gland Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1055\/s-0041-1740132","article-title":"Axilla versus wrist as the recipient site in vas-cularized lymph node transfer for breast cancer-related lymphedema: A systematic review and meta-analysis","volume":"38","author":"Chocron","year":"2022","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1097\/SLA.0000000000005591","article-title":"A prospective study on the safety and efficacy of vascularized lymph node transplant","volume":"276","author":"Brown","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1286","DOI":"10.1097\/PRS.0b013e31828bd3b3","article-title":"Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes","volume":"131","author":"Cheng","year":"2013","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"418","DOI":"10.21037\/atm-23-292","article-title":"Surgical management of breast cancer-related lymphedema: A narrative review of contemporary practices","volume":"11","author":"Ciudad","year":"2023","journal-title":"Ann. Transl. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1002\/jso.25360","article-title":"Combined double vascularized lymph node transfers and modified radical reduction withpreservation of perforators for advanced stages of lymphedema","volume":"119","author":"Ciudad","year":"2019","journal-title":"J. Surg. Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1002\/micr.30508","article-title":"Comparisons in long-term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer","volume":"40","author":"Ciudad","year":"2020","journal-title":"Microsurgery"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1016\/j.jamcollsurg.2017.08.001","article-title":"Vascularized jejunal mesenteric lymph node transfer: A novel surgical treatment for extremity lymphedema","volume":"225","author":"Coriddi","year":"2017","journal-title":"J. Am. Coll. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1089\/lrb.2018.0028","article-title":"Correlation of L-Dex bioimpedance spectroscopy with limb volume and lymphatic function in lymphedema","volume":"17","author":"Coroneos","year":"2019","journal-title":"Lymphat. Res. Biol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1097\/PRS.0000000000000822","article-title":"Reverse lymphatic mapping: A new technique for maximizing safety in vascularized lymph node transfer","volume":"135","author":"Dayan","year":"2015","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1673","DOI":"10.1097\/PRS.0000000000002169","article-title":"Breast cancer-related lymphedema: Quality of life after lymph node transfer","volume":"137","author":"Zeltzer","year":"2016","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1002\/micr.30924","article-title":"A comparative study between deep inferior epigastric artery perforator flap breast reconstruction and DIEP flap breast reconstruction coupled with vascularized lymph node transfer: Improving the quality of life of patients with breast cancer related lymphedema without affecting donor site outcomes","volume":"43","author":"Coleman","year":"2023","journal-title":"Microsurgery"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1007\/s10549-016-3716-0","article-title":"A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer","volume":"156","author":"Dionyssiou","year":"2016","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"911","DOI":"10.1002\/jso.25650","article-title":"Functional lymphatic reconstruction with the \u201cSelected Lymph Node\u201d technique guided by a SPECT-CT lymphoscintigraphy","volume":"120","author":"Dionyssiou","year":"2019","journal-title":"J. Surg. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1076","DOI":"10.1097\/SLA.0000000000002322","article-title":"Outcomes of lymphedema microsurgery for breast cancer-related lymphedema with or without microvascular breast reconstruction","volume":"268","author":"Engel","year":"2018","journal-title":"Ann. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1002\/jso.24158","article-title":"A comprehensive review of the natural lymphaticovenous communications and their role in lymphedema surgery","volume":"113","author":"Mirapeix","year":"2016","journal-title":"J. Surg. Oncol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1007\/s10549-022-06778-y","article-title":"Combining reconstructive and ablative surgical treatment of chronic breast cancer-relatedlymphedema (BCRL): Safe and effective","volume":"197","author":"Ghazaleh","year":"2023","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1475","DOI":"10.1245\/s10434-016-5614-4","article-title":"Clinical and psychosocial outcomes of vascularized lymph node transfer for the treatment of upper extremity lymphedema after breast cancer therapy","volume":"24","author":"Gratzon","year":"2017","journal-title":"Ann. Surg. Oncol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1016\/j.bjps.2020.10.012","article-title":"Decreasing donor site morbidity after groin VLNT: Lessons from a 12-year experience and literature review","volume":"74","author":"Hamdi","year":"2021","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e1923","DOI":"10.1097\/GOX.0000000000001923","article-title":"Comparisons of submental and groin vascularized lymph node flaps transfer for breast cancer-related lymphedema","volume":"6","author":"Ho","year":"2018","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e2003","DOI":"10.1097\/GOX.0000000000002003","article-title":"Effectiveness of Vascularized Lymph Node Transfer for Extremity Lymphedema Using Volumetric and Circumferential Differences","volume":"7","author":"Ho","year":"2019","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1002\/jso.24347","article-title":"Latissimus dorsi flap with VLNT for lymphedema treatment: Technique, outcomes, indications and literature review","volume":"115","author":"Inbal","year":"2017","journal-title":"J. Surg. Oncol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e2436","DOI":"10.1097\/GOX.0000000000002436","article-title":"Flow-through Omental Flap for Vascularized Lymph Node Transfer: A Novel Surgical Approach for Delayed Lymphatic Reconstruction","volume":"7","author":"Johnson","year":"2019","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"S234","DOI":"10.1097\/SAP.0000000000001864","article-title":"Lymphedema incidence after axillary lymph node dissection: Quantifying the impact of radiation and the lymphatic microsurgical preventive healing approach","volume":"82","author":"Johnson","year":"2019","journal-title":"Ann. Plast. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1007\/s10549-024-07567-5","article-title":"VLNT versus LV A for chronic BCRL: A retrospective cohort study of effectiveness over time","volume":"210","author":"Kappos","year":"2025","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e090662","DOI":"10.1136\/bmjopen-2024-090662","article-title":"The LYMPH trial: Comparing microsurgical with conservative treatment for chronic breast cancer-associated lymphoedema\u2014Study protocol of a pragmatic randomised international multicentre superiority trial","volume":"15","author":"Kappos","year":"2025","journal-title":"BMJ Open"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1413","DOI":"10.1002\/jso.25033","article-title":"Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema","volume":"117","author":"Kenworthy","year":"2018","journal-title":"J. Surg. Oncol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1002\/jso.25523","article-title":"Factors associated with professional healthcare advice seeking in breast cancer-related lymphedema","volume":"121","author":"Lin","year":"2020","journal-title":"J. Surg. Oncol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1016\/j.bjps.2018.02.015","article-title":"Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism","volume":"71","author":"Liu","year":"2018","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1002\/jso.24351","article-title":"The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: A prospective study of 100 consecutive cases","volume":"115","author":"Maldonado","year":"2017","journal-title":"J. Surg. Oncol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"892","DOI":"10.1016\/j.bjps.2019.01.029","article-title":"Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients\u2019 related outcomes. A retrospective comparative study","volume":"72","author":"Maruccia","year":"2019","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1002\/micr.30511","article-title":"Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema","volume":"39","author":"Maruccia","year":"2019","journal-title":"Microsurgery"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1055\/s-0035-1544182","article-title":"Combined Surgical Treatment in Breast Cancer-Related Lymphedema","volume":"32","author":"Masia","year":"2016","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"5213","DOI":"10.1200\/JCO.2008.16.3725","article-title":"Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: Objective measurements","volume":"26","author":"McLaughlin","year":"2008","journal-title":"J. Clin. Oncol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"e2156","DOI":"10.1590\/0100-6991e-20192156","article-title":"Influence of vascularized lymph node transfer (VLNT) flap positioning on the response to breast cancer-related lymphedema treatment","volume":"46","author":"Montag","year":"2019","journal-title":"Rev. Col. Bras. Cir."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1002\/micr.30079","article-title":"Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications","volume":"38","author":"Scaglioni","year":"2018","journal-title":"Microsurgery"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"2827","DOI":"10.1245\/s10434-017-5964-6","article-title":"Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options","volume":"24","author":"McLaughlin","year":"2017","journal-title":"Ann. Surg. Oncol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"975","DOI":"10.1097\/PRS.0000000000007783","article-title":"Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference","volume":"147","author":"Chang","year":"2021","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1097\/PRS.0000000000005993","article-title":"Surgical Treatment of Lymphedema","volume":"144","author":"Schaverien","year":"2019","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"2424","DOI":"10.1245\/s10434-014-4276-3","article-title":"A prospective evaluation of lymphedema-specific quality-of-life outcomes fol-lowing vascularized lymph node transfer","volume":"22","author":"Patel","year":"2015","journal-title":"Ann. Surg. Oncol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1007\/s10238-024-01344-w","article-title":"Improving quality of life after breast cancer: A comparison of two microsurgical treatment options for BCRL","volume":"24","author":"Seidenstuecker","year":"2024","journal-title":"Clin. Exp. Med."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1016\/j.bjps.2018.10.010","article-title":"Compartimental harvesting of dual lymph node flap from the right supraclavicular area for the treatment of lower extremity lymphedema: A case series","volume":"72","author":"Visconti","year":"2019","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"817","DOI":"10.1097\/00006534-197963060-00007","article-title":"Successful lymph node transplantation in rats, with restoration of lymphatic function","volume":"63","author":"Shesol","year":"1979","journal-title":"Plast. Reconstr. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/20\/7281\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,17]],"date-time":"2025-10-17T04:15:50Z","timestamp":1760674550000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/20\/7281"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,15]]},"references-count":52,"journal-issue":{"issue":"20","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["jcm14207281"],"URL":"https:\/\/doi.org\/10.3390\/jcm14207281","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,15]]}}}