Purpose: Recent reports have demonstrated that lymphedema can occur after even minor pertubation of the axillary region such as sentinel lymph node biopsy (SLNB). Breast reconstruction is routinely performed after mastectomy and often involves dissection in the axillary area. The impact of breast reconstruction on the development of lymphedema, however, remains unknown. Therefore, the purpose of this study was to determine the impact of immediate breast reconstruction on the risk of developing lymphedema in a prospectively followed cohort of patients.
Methods: From our prospectively maintained lymphedema outcomes database of 1,002 patients we identified 341 patients in our prospectively maintained breast reconstruction database who had undergone mastectomy with SLNB or SLNB and axillary lymph node dissection (ALND). The development of lymphedema was evaluated prospectively using arm measurements performed before and after surgery as well as with The Lymphedema and Breast Cancer Questionnaire. Associations between variables were examined using Fisher’s exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic regression was used to examine the association of reconstruction on prevalence of lymphedema while adjusting individually for BMI, age, weight gain after surgery.
Results: Characteristics of patients with or without reconstruction were similar except for age, BMI, and weight gain since surgery. The median follow-up was 5 years. Among patients treated with mastectomy with SLNB or SLNB/ALND, those undergoing reconstruction had a lower rate of measured lymphedema than those who did not (8% vs 27%, p<0.001). The reconstructed group also had fewer patients with both measured and self reported lymphedema (6% vs 20%, p<0.01). Reconstruction did not increase the risk of lymphedema regardless of whether patients underwent SLNB alone, or if they underwent SLNB followed by ALND. Interestingly, differences in the rates of measured lymphedema between the 2 groups persisted even following univariate logistical regression for differences in age, BMI, and weight gain indicating a complex interaction between these and possibly other lymphedema risk factors in contributing to the lower rates of lymphedema in the reconstructed patients. Logistic regression controlling for all variables could not be performed reliably due to inadequate statistical power.
Conclusions: Breast reconstruction in patients undergoing SLNB or SLNB/ALND does not increase the risk of developing either measured or perceived lymphedema. To our knowledge, this is the first study to objectively demonstrate that reconstruction does not increase the risk of developing lymphedema in patients undergoing axillary lymphadenectomy for the treatment of breast cancer. A larger cohort would allow for multivariate analysis of confounding variables.

Prevalence of lymphedema by reconstruction status

	Reconstruction (N=211)	No Reconstruction (N=130)	P Value
	N (%)	N (%)
Objectively Measured Lymphedema
Overall Measured Lymphedema	12 (6%)	24 (18%)	0.0004
Severe Lymphedema	2 (1%)	5 (4%)	0.1105
Objective and Subjective Lymphedema
Perceived Lymphedema	25 (12%)	28 (22%)	0.0207
Both Measured and Perceived	6 (3%)	16 (12%)	0.0046
Perceived but not Measured	19 (9%)	12 (9%)	ns
Measured but not Perceived	6 (3%)	8 (6%)	ns