Where does subcutaneous lymph from the chest wall flow into after mastectomy?

Published:April 18, 2021DOI:



      Changes of the lymph flow from the chest wall after mastectomy and sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (Ax) has yet to be understood. This study aimed to investigate the effect of axillary surgery on lymphatic flow from the chest wall in patients who have undergone mastectomy, including those have undergone breast reconstruction and vascularized lymph node transfer (VLNT).


      Following mastectomy in 100 breasts, the directions of lymph flow from the chest wall was compared between the SLNB omission, SLNB, Ax, and Ax followed by VLNT groups using indocyanine green (ICG) lymphography in cross-sectional study. Lymph flow on the deep epigastric artery perforator (DIEP) flap was also investigated.


      Lymph flow directing to the ipsilateral axilla was observed more frequently after SLNB than Ax (48% vs. 12.5%; p = 0.005); however, no significant difference was observed in the frequency of contralateral axillary route adoption between them (8% vs. 15%; p = 0.65). In the VLNT group, lymph flow to the ipsilateral axilla was not observed at a significantly higher frequency than in the Ax group (12.5% vs. 12.5%, p = 1.00). On the transferred DIEP flap, the lymph flowed anterograde or retrograde parallel to the anatomic course of the lymphatic vessels.


      To visualize the direction of lymph flow of the chest following mastectomy, ICG lymphography may be useful to discern the direction in which malignant neoplasms, including lymphoma, are transported and to plan for lymph flow restoration.


      To read this article in full you will need to make a payment


        • Suami H
        • Pan WR
        • Mann GB
        • Taylor GI.
        The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study.
        Ann Surg Oncol. 2008; 15: 863-871
        • Suami H.
        Lymphosome concept: anatomical study of the lymphatic system.
        J Surg Oncol. 2017; 115: 13-17
        • Pavlista D
        • Eliska O.
        Cutaneous and subcutaneous lymphatic drainage of the breast.
        Lymphology. 2005; 38: 92-102
        • Veronesi U
        • Paganelli G
        • Galimberti V
        • et al.
        Sentinel-node biopsy to avoid acillary dissection in breast cancer with clinically negative lymph-nodes.
        Lancet. 1997; 349: 1864-1867
        • Borgstein PJ
        • Meijer S
        • Pijpers R.
        Intradermal blue dye to identify sentinel lymph nodes in breast cancer.
        Lancet. 1997; 349: 1668-1669
        • Linehan DC
        • Hill AD
        • Akhurst T
        • et al.
        Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients.
        Ann Surg Oncol. 1999; 6: 450-454
        • Sávolt Á
        • Cserni G
        • Lázár G
        • et al.
        Sentinel lymph node biopsy following previous axillary surgery in recurrent breast cancer.
        Eur J Surg Oncol. 2019; 45: 1835-1838
        • Sato A
        • Sakai T
        • Iwase T
        • et al.
        Altered lymphatic drainage patterns in re-operative sentinel lymph node biopsy for ipsilateral breast tumor recurrence.
        Radiat Oncol. 2019; 14: 159
        • Matsumoto A
        • Jinno H
        • Nakamura T
        • et al.
        Technical feasibility of sentinel lymph node biopsy in patients with ipsilateral breast tumor recurrence and previous axillary surgery.
        Int J Surg. 2015; 22: 28-31
        • Intra M
        • Viale G
        • Vila J
        • Grana CM
        • et al.
        Second axillary sentinel lymph node biopsy for breast tumor recurrence: experience of the european institute of oncology.
        Ann Surg Oncol. 2015; 22: 2372-2377
        • Pasta V
        • Monteleone F
        • D'Orazi V
        • et al.
        Typical and atypical lymphatic flows in breast carcinoma.
        Ann Ital Chir. 2015; 86: 311-316
        • Tokmak H
        • Kaban K
        • Muslumanoglu M
        • et al.
        Management of sentinel node re-mapping in patients who have second or recurrent breast cancer and had previous axillary procedures.
        World J Surg Oncol. 2014; 12: 205
        • Maaskant-Braat AJ
        • Roumen RM
        • Voogd AC.
        Sentinel node and recurrent breast cancer (SNARB): results of a nationwide registration study.
        Ann Surg Oncol. 2013; 20: 620-626
        • Schaverien MV
        • Coroneos CJ.
        Surgical treatment of lymphedema.
        Plast Reconstr Surg. 2019; 144: 738-758
        • Clemens M.W.
        • Medeiros L.J.
        • Butler C.E.
        • et al.
        Complete surgical excision is essential for the management of patients with breast implant-associated anaplastic large-cell lymphoma.
        Journal of Clinical Oncology;. 2016; 34: 160-168
        • Belmonte R
        • Messaggi-Sartor M
        • Ferrer M
        • et al.
        Prospective study of shoulder strength, shoulder range of motion, and lymphedema in breast cancer patients from pre-surgery to 5 years after ALND or SLNB.
        Support Care Cancer. 2018;
        • Killelea BK
        • Long JB
        • Dang W
        • et al.
        Associations between sentinel lymph node biopsy and complications for patients with ductal carcinoma in situ.
        Ann Surg Oncol. 2018; 25: 1521-1529
        • Bhatt NR
        • Boland MR
        • McGovern R
        • et al.
        Upper limb lymphedema in breast cancer patients in the era of Z0011, sentinel lymph node biopsy and breast conservation.
        Ir J Med Sci. 2018; 187 (327-1)
        • Boughey JC
        • Suman VJ
        • Mittendorf EA
        • et al.
        Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOGZ1071 (Alliance) clinical trial.
        JAMA. 2013; 310: 1455-1461
        • Saaristo AM
        • Niemi TS
        • Viitanen TP
        • et al.
        Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients.
        Ann Surg. 2012; 255: 468-473
        • Becker C
        • Pham DN
        • Assouad J
        • et al.
        Postmastectomy neuropathic pain: results of microsurgical lymph nodes transplantation.
        Breast. 2008; 17: 472-476
        • Akita S
        • Tokumoto H
        • Yamaji Y
        • et al.
        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.
        J Reconstr Microsurg. 2017; 3: 571-578
        • Cheng MH
        • Huang JJ
        • Wu CW
        • et al.
        The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage.
        Plast Reconstr Surg. 2014; 133 (192e-8e)
        • Ito R
        • Zelken J
        • Cheng MH
        • et al.
        Proposed pathway and mechanism of vascularized lymph node flaps.
        Gynecol Oncol. 2016; 141: 182-188
        • Yamamoto T
        • Yoshimatsu H
        • Yamamoto N.
        Complete lymph flow reconstruction: a free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis.
        J Plast Reconstr Aesthet Surg. 2016; 69: 1227-1233
        • Akita S
        • Yamaji Y
        • Tokumoto H
        • et al.
        Improvement of the efficacy of vascularized lymph node transfer for lower-extremity lymphedema via a prefabricated lympho-venous shunt through lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated vascularized lymph node.
        Microsurgery. 2018; 38: 270-277
        • Yoshimatsu H
        • Visconti G
        • Karakawa R
        • et al.
        Lymphatic system transfer for lymphedema treatment: transferring the lymph nodes with their lymphatic vessels.
        Plast Reconstr Surg Glob Open. 2020; 8: e2721
        • Adams KE
        • Rasmussen JC
        • Darne C
        • et al.
        Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema.
        Biomed Opt Express. 2010; 1: 114-125
        • Akita S
        • Nakamura R
        • Yamamoto N
        • et al.
        Early detection of lymphatic disorder and treatment for lymphedema following breast cancer.
        Plast Reconstr Surg. 2016; 138 (192e–202e)
        • Tourani SS
        • Taylor GI
        • Ashton MW.
        Scarpa fascia preservation in abdominoplasty: does it preserve the lymphatics?.
        Plast Reconstr Surg. 2015; 136: 258-262
        • Clemens M.W.
        • Medeiros L.J.
        • Butler C.E.
        • et al.
        Complete surgical excision is essential for the management of patients with breast implant-associated anaplastic large-cell lymphoma.
        Journal of Clinical Oncology. 2016; 34: 160-168
        • Dayan JH
        • Dayan E
        • Smith ML.
        Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer.
        Plast Reconstr Surg. 2015; 135: 277-285
        • Zhang H
        • Chen W
        • Mu L
        • et al.
        The distribution of lymph nodes and their nutrient vessels in the groin region: an anatomic study for design of the lymph node flap.
        Microsurgery. 2014; 34: 558-561
        • Yamamoto T
        • Iida T
        • Yoshimatsu H
        • et al.
        Lymph flow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph flow reconstruction without lymph node transfer or lymphatic anastomosis.
        Plast Reconstr Surg. 2018; 142: 796-804
        • Cheville AL
        • Brinkmann DH
        • Ward SB
        • et al.
        The addition of SPECT/CT lymphoscintigraphy to breast cancer radiation planning spares lymph nodes critical for arm drainage.
        Int J Radiat Oncol Biol Phys. 2013; 85 (15): 971-977