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Figure 2. Magnified, intra-operative view of an lymphatico-venous anastomosis

Lymphaticolymphatic bypass
This procedure has been popularized by Baumeister et al. [37,38] . Healthy lymphatic vessels are harvested
from the lower extremity, used as a graft, and are inset subcutaneously under the skin of the anterior
shoulder, between the upper arm and the neck. The ends of the grafted lymphatic vessels are anastomosed
to recipient lymphatic vessels in the arm and supraclavicular region. Despite lymphoscintigraphy
demonstrating the patency of lymphatic vessels in the graft and a significant reduction of arm volume, this
technique leads to a long scar at the donor site and the risk of lymphedema in the donor lower limb cannot
[39]
be excluded [1,20] . In turn, Campisi et al. described the use of an autologous vein graft in a similar manner
to bypass the lymphatic obstruction, thereby sparing the lymphatic vessels in the donor site.

Fat grafting
Adipose-derived stem cells (ADSCs) are mesenchymal stem cells that can be collected through liposuction
easily as fat tissue is an abundant and easily accessible source of ADSCs [40,41] . Recently, animal studies have
demonstrated that the administration of ADSCs can increase the number of lymphatic vessels and improve
[42]
secondary lymphedema . The capacity of ADSCs to induce lymphaniogenesis seems to be mediated by
VEGF-C and the release of other lymphangiogenetic factors. Saijo et al. studied the paracrine effects
[40]
of ADSCs in promoting lymphangiogenesis in irradiated lymphatic endothelial cells in vitro. The results
obtained suggest that ADSCs could have a role in the treatment of secondary-post irradiation limb
lymphedema. Yet, few papers have described fat grafting in the axilla to improve BCRL clinically [41,43-45] .
[45]
Maruccia et al. retrospectively compared the efficacy of upper limb circumference reduction and the
improvement in patients’ quality of life between VLNT alone and VLNT plus scar revision through fat
[43]
grafting with better outcomes reported in the latter. Toyserkani et al. however, only reported a modest
decrease in excess arm volume, that was not significant, after similar scar revision by means of fat grafting
and ADSC injection in the axilla. Better results though were achieved in ISL stage I than in ISL stage II
BCRL. The authors also observed an improvement in lymphedema symptoms and the decreased need for
conservative treatment for the majority of patients. Recently, Toyserkani et al. reported similar results
[44]
after a 1-year period of follow-up. Quantitative lymphoscintigraphy was used to evaluate upper limb lymph
drainage after ADSC injection in the axilla but no significant improvement was observed.