The "lymphatico-lymphatic bridge" technique: Maximising lymphatic drainage in challenging scenarios in supermicrosurgical lymphaticovenous anastomosis.

Proximal lymphaticovenous anastomosis (LVA) achieves superior limb decompression; however, recipient veins in this region are often deep and disproportionately large in caliber relative to small lymphatic vessels (LVs). The resulting size mismatch frequently forces surgeons to forgo anastomoses with several LVs, undermining drainage, and no current technique reliably resolves this constraint. We developed the Lymphatico-Lymphatic Bridge (LLB), a sequential end-to-side method that uses an adjacent LV as an autologous conduit, linking otherwise unreachable LVs to a single recipient vein. The LLB was added to > 2,800 LVAs when LVs were distant or undersized. The procedure avoids extra incisions or vein grafts and may enhance antegrade washout while reducing venous reflux. Preliminary follow-up results show limb-volume reduction comparable to that of standard LVA. By incorporating additional proximal LVs, the LLB broadens indications for proximal LVA and may augment lymphatic pressure, thereby improving early patency. These findings support a proximal-first strategy for LVA surgery and warrant prospective controlled evaluation.