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Breast lymphedema (BLE) is an underrecognized sequela of breast cancer treatment that can lead to chronic swelling, pain, and recurrent infections. While lymphovenous anastomosis (LVA) is well established for the management of extremity lymphedema, its application to BLE has rarely been described. Here, we discuss a case of LVA for refractory BLE following delayed autologous reconstruction. A 49-year-old woman developed severe left-sided BLE after deep inferior epigastric artery perforator flap reconstruction. The clinical course was complicated by nine episodes of cellulitis requiring hospital admission for intravenous treatment despite compliance with prophylactic antibiotics and compression therapy. The patient underwent indocyanine green (ICG)-guided supermicrosurgical LVA within the reconstructed breast. Immediate postoperative decongestion was observed, and substantial reductions in breast pain and improvements in symmetry were reported 1 month postoperatively. At 10 months postoperatively, the patient maintained durable reductions in swelling and infection frequency. Our experience showed that LVA may be safely and effectively performed in the reconstructed breast and may represent a viable physiologic option for patients with refractory BLE unresponsive to conservative therapy.