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Page 2 of 12 Jabbour et al. Plast Aesthet Res 2021;8:43 https://dx.doi.org/10.20517/2347-9264.2021.59

the United States and most industrialized nations across the world. The combination of surgical resection,
including regional nodal dissections, chemotherapy, and radiation therapy, places patients at significant
[1-4]
risks for developing lymphedema due to compromised drainage of lymphatic fluid from the limb . As the
obstruction progresses, the lymphatic fluid leaks into the surrounding subcutaneous tissue leading to a
vicious cycle of inflammation that further compromises the drainage from the limb resulting in fat
deposition and fibrosis. Historically, treatment focused on ablative procedures to reduce and remove the fat
and fluid from the arm or leg via direct excision or liposuction. However, modern techniques for the
treatment of lymphedema focus on physiological approaches aimed to restore the drainage of lymphatic
fluid from the affected limb .
[5-8]

One option is the lymphovenous bypass (LVB), where an anastomosis is completed between a lymphatic
vessel and a recipient venule [9,10] . Given the small size of the vessels, the concept of super microsurgery was
coined, designating the surgical repair of these vessels that are less than one millimeter in size [Figure 1].
With the advancements in the design of specialized instruments, microscopic sutures, improved optics in
operative microscopes, different imaging modalities, and experience, this approach has proven to be an
effective and reproducible method to allow the lymphatic fluid to drain into the systemic circulation,
thereby restoring the egress of fluid from the extremity. As the fluid drains into the bloodstream, the
swelling improves, and the overwhelming majority of patients find an improvement in the heaviness of their
arm or leg, decreased dependency on compression garments and need for conservative therapies, and
reduced risks and frequency of infection and cellulitis. Early studies demonstrated efficacy only with early-
stage lymphedema, but more recent studies suggest that the technique can also be extremely effective even
in late-stage and more advanced lymphedema [11,12] .

The second option that has also grown in popularity in recent times is the vascularized lymph node transfer
(VLNT). Studies have demonstrated improvements in patients who have undergone this operation where
lymph nodes are taken from one location and transferred to the affected extremity. The precise mechanism
of action remains unknown, but the two predominant theories are either via a pump mechanism or through
lymphangiogenesis [13-15] . A number of different donor sites have been described, the most popular of which
include the supraclavicular nodes, the submental nodes, the lateral thoracic nodes, the inguinal nodes, and
intra-abdominal nodes, including the gastroepiploic nodes or the omentum and the mesenteric nodes .
[16]
Most super microsurgeons specializing in VLNT have a preferred donor site and have reported consistent
outcomes confirming the efficacy of lymph node transfers; however, regardless of which donor site is
selected, the effectiveness seems to be equivalent except for the lateral thoracic nodes, which have higher
complication rates compared to the other donor sites . Overall, the outcomes using the lymph node
[17]
transfer approach have proven to be promising, and more and more data has continued to confirm its
efficacy.

Lymphovenous bypass
The lymphovenous bypass procedure has been popularized by Koshima et al. and led to a resurgence of
[18]
this technique for the treatment of lymphedema in a variety of different areas, but most commonly in the
arms and legs. The technique is based on the localization of the remaining lymphatic vessels in the affected
area that can be rerouted, creating a shunt from the obstructed lymphatic system into the systemic
circulation. The vessels are typically less than one millimeter in size, which has led to the term super
microsurgery, and with the modern technology available, the anastomosis can be readily completed by
trained microsurgeons. Occasionally, the vessels can be larger, allowing the anastomosis to be completed
using a venous coupling device (Synovis, Inc., Alabama) . Whether a coupled LVB or a hand-sewn LVB is
[19]
superior remains to be determined, but perhaps the use of the coupler may improve the long-term patency
of the LVB, preventing compression and thrombosis of the bypass [Figure 2].