BlueCross BlueShield of Tennessee Medical Policy Manual

Lymphatic Physiologic Microsurgery for Breast Cancer-Related Lymphedema


Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema), but is most often caused by acquired damage to the lymphatic system (secondary lymphedema). Breast cancer treatment is one of the most common causes of secondary lymphedema. Both the surgical removal of lymph nodes and radiotherapy are associated with the development of lymphedema in individuals with breast cancer.

Physiological microsurgical techniques have been developed in an effort to improve lymphatic circulation and thereby decrease symptoms and risk of infection. These surgical interventions can be broadly grouped into two procedures:

  1. Reconstruct or bypass the obstructed lymphatic vessels to improve lymphatic drainage (lymphatico-lymphatic bypass, lymphovenous bypass and lymphaticovenular anastomosis)

Preventative lymphaticovenular anastomosis is performed during nodal dissection or reconstructive surgery and involves anastomosing arm lymphatics to a collateral branch of an axillary vein. This procedure is also known as the Lymphatic Microsurgical Preventing Healing Approach (LYMPHA).

  1. Transfer lymph tissue into an obstructed area to reestablish lymphatic flow (autologous lymph node transplantation and vascularized lymph node transfer).




There is a lack of high-quality evidence published in peer-reviewed journals to evaluate the effectiveness of this technology on health outcomes.


BlueCross BlueShield Association. Evidence Positioning System. (7:2018). Surgical treatments for breast cancer-related lymphedema (7.01.162). Retrieved October 15, 2018 from (23 articles and/or guidelines reviewed)

Cornelissen, A.J.M., Beugels, J., Ewalds, L., Heuts, E.M., Keuter, X.H.A., Piatkowski, A., et al. (2018). The effect of lymphaticovenous anastomosis in breast cancer-related lymphedema: a review of the literature. Lymphatic Research and Biology, 2018 Jan 22. Doi: 10.1089/lrb.2017.0067. [Epub ahead of print]. Abstract retrieved October 16, 2018 from PubMed database.

Demiri, E., Dionyssiou, D., Tsimponis, A., Goula, O.C., Milothridis, P., Pavilidis, L., et al. (2018). Donor-site lymphedema following lymph node transfer for breast cancer-related lymphedema: a systematic review of the literature. Lymphatic Research and Biology, 16 (1), 2-8. Abstract retrieved October 16, 2018 from PubMed database.

Dionyssiou, D., Demiri, E., Tsimponis, A., Sarafis, A., Mpalaris, V., Tatsidou, G., & Arsos, G. (2016). A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer. Breast Cancer Research and Treatment, 156 (1), 73-79. Abstract retrieved October 16, 2018 from PubMed database.

Jørgensen, M.G., Touserkani, N.M., & Sørensen, J.A. (2017). The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery, 2017 Mar 28. Doi: 10.1002/micr.30180. [Epub ahead of print].

Nguyen, A.T., Suami, H., Hanasono, M.M., Womack, V.A., Wong, F.C., & Chang, E.I. (2017). Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. Journal of Surgical Oncology, 115 (1), 84-89. Abstract retrieved October 16, 2018 from PubMed database.

Scaglioni, M.F., Arvanitakis, M., Chen, Y.C., Giovanoli, P., Chia-Shen Yang, J., & Chang, E. (2018). Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications.  Microsurgery, 38 (2), 222-229. Abstract retrieved October 16, 2018 from PubMed database.

Scaglioni, M.F., Fontein, D.B.Y., Arvanitakis, M., & Giovanoli, P. (2017). Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery, 37 (8), 947-953. Abstract retrieved October 16, 2018 from PubMed database.

Winifred S. Hayes, Inc. Medical Technology Directory. (2017 May; last update search May 2018). Surgical treatment of lymphedema: a review of reviews. Retrieved October 16, 2018 from (20 articles and/or guidelines reviewed)




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