Patient selection criteria

Approval for the study was granted by the ethics committee of the Third Affiliated Hospital of Kunming Medical University. We confirmed that all methods were performed in accordance with the relevant guidelines and regulations. All of the patients sighed informed consent. After completion of breast surgery and radiotherapy by both surgeons and radiation oncologists at this hospital, patients were assessed at regular intervals, ranging from 3 months to 1 year. Circumferential limb measurements were taken at six anatomical points: the palm of the hand between the thumb and the index finger, the wrist, the median of the forearm, the elbow through the olecranon, and the median and the root of the upper arm. According to the swelling severity, three levels of BCRL were classified. Mild oedema was diagnosed when the circumference of the affected limb was 0–3 cm larger than that of the intact side or when the swelling was limited to the proximal side of the upper limb; moderate oedema was diagnosed when the circumference of the affected limb was 3.1–6 cm larger than that of the intact side or the swelling extended to the forearm and palm; and severe oedema was diagnosed when the circumference of the affected limb was ≥6 cm larger than that of the intact side or the oedema caused symptomatic restriction of arm movement. Persistent oedema was only scored if the symptoms were not resolved at subsequent visits. For this study, we only enrolled patients with persistent moderate to severe oedema related to BCRL, which is oedema that lasts more than half a year. Twenty patients with BCRL after modified radical mastectomy were enrolled between November 2012 and October 2014: 12 were enrolled between November 2012 and November 2013, and 8 were enrolled between December 2013 and October 2014. BCRL patients willing to undergo breast reconstruction were enrolled in the lymphatic TRAM/DIEP group (n = 10), and BCRL patients unwilling to undergo breast reconstruction were enrolled in physiotherapy (n = 10).

None of these 20 patients had previously undergone surgery with a TRAM flap, abdominal suction-assisted lipectomy, or abdominal surgery leading the deep inferior epigastric vessels divided or damaged. They also had none significant medical co-morbidities that make them poor surgical candidates. In the surgery group, 1 patient was a cigarette smoker and 2 were obese. These 3 received a TRAM flap, whereas the other 7 were treated using the DIEP strategy. Physiotherapy for patients in the physical therapy group included pneumatic compression and decongestive bandage depression.