Background Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning. Methods A single-center retrospective review was performed (2019–2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded. Results There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001). Conclusion Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.

Breast cancer-related lymphedema (BCRL) is the most common cause of secondary lymphedema in the Western world and occurs in up to one-third of breast cancer survivors following axillary lymph node dissection (ALND). Compression of the affected limb is a mainstay of therapy. Surgical management of BCRL involves excision of excess fibroadipose tissue and physiologic procedures to improve fluid retention in the limb. Once lymphedema is established, the inflammatory cascade and fibrosis render the disease hard to reverse. The purpose of this review is to elucidate existing management strategies for prevention of breast cancer-related lymphedema. A literature search was conducted using PubMed, Ovid, Embase, and Scopus. Articles that included management strategies for prevention of BCRL were selected for review. Immediate lymphatic reconstruction (ILR) is a microsurgical technique that connects disrupted axillary lymphatic vessels to nearby veins by lymphovenous anastomoses at the time of ALND and has been shown to reduce rates of lymphedema from 30% to 4–12%. BCRL remains incurable. Immediate lymphatic reconstruction has emerged as a preventative strategy to reduce rates of lymphedema in breast cancer patients.

Postmastectomy patients may choose to not have breast reconstruction and opt for a flat closure. Aesthetic flat closure (AFC) is intentional incision selection and maneuvers for chest wall contour to optimize the aesthetic result. Patients may have a specific expectation of aesthetic outcomes, making AFC a new type of reconstruction. The purpose of this study is to perform a scoping review to define 1) patients who receive flat closure after mastectomy for treatment of breast cancer and their motivations for flat closure, 2) surgical techniques used to accomplish AFC, and 3) patient-reported outcomes of flat closure. A systematic search was conducted through MEDLINE, Embase, and Scopus. Articles were grouped into three overall categories of population description, surgical techniques, and outcomes. Within each category, major themes were identified. The literature search identified 48 articles and 15 met study criteria. Those who had no breast reconstruction considered risks, breast functionality, recovery time, and foreign body placement. Studies reported lack of surgeon support in patients’ decisions for flat closure. Surgical techniques for AFC included scar placement at the inframammary fold, medial and lateral debulking, and dog ear prevention. There were 89.9 % (328/365) of patients who were satisfied in choosing a flat closure and 58.2 % (689/1183) were satisfied with cosmesis. Patients chose flat closure for various reasons including avoiding additional surgery. Surgeon supported decision-making and comprehensive education on reconstructive and non-reconstructive options are critical to patient experiences. While patients are satisfied with their decision of flat closure, optimization of aesthetic results can be achieved by implementing chest wall reconstruction techniques with the specific goal of obtaining an AFC.