# Lymphedema Surgical Treatment Using BioBridgeTM: A Preliminary Experience
## 1 Introduction  
Lymphedema (LE) is a progressive chronic disorder characterized by the accumulation of fluids, proteins, and cell debris in the interstitial compartment, as the result of an impairment of lymphatic functioning. It can affect any part of the body, most commonly the extremities, and in its early phases, it is frequently interpreted as a simple swelling or edema. LE should be clinically distinguished from other causes of extremity edema and enlargement due to fluid retention or osmotic imbalance, skin diseases such as crysipelas, cardiac failure, or venous insufficiency [1]. It may be congenital (primary) or related to cancer treatments or infectious diseases such as phylariosis (secondary) [2]. In Western countries, it represents a complication in cancer survivors with a global incidence of 15.5% and a reported rate of up to 60% in women who have undergone breast cancer surgery and radiotherapy [3]. Major attempts to lower the prevalence of lymphedema have been concentrated on early diagnosis, improvements in surgical procedures for cancer surgeries, and a mix of several imaging modalities that can be performed pre-, intra-, and postoperatively, because there are still few viable therapeutic options. LE remains a chronic condition, characterized by progressive increase in the affected limbs/anatomical areas, with recurrent infections and impaired quality of life. In recent years, imaging of LE with magnetic resonance and indocyanine green lymphography has led to a significant development. Magnetic resonance lymphography with or without injection of the subcutaneous contrast medium has enabled accurate detection, staging, and characterization of the disease, with identification of aplastic, ipoplastic, and hyperplastic LE patterns allowing doctors to target specific surgical strategies [4; 5]; indocyanine green lymphography represents a useful tool in surgery as it visualizes superficial lymphatic vessels [6]. LE has traditionally been treated in conservative ways, including bandages, manual lymphatic drainage, and physiotherapy; however, in recent years, new surgical techniques, namely vascularized lymph-node transfer, and venolymphatic anastomoses have shown promising results for LE treatment and have gained popularity [7; 8]. Vascularized lymph node transfer consists of the harvesting of superficial lymph nodes and surrounding fat as a tissue flap from a healthy donor site and its implantation into aymphedematous limb [9]. A lymph node flap includes lymph nodes and lymphatic-vessel network while avoiding disrupting their normal function. Arterial and venous anastomoses are then created to provide blood supply to the transplanted tissue flap [9]. A venolymphatic anastomosis, also known as a lymphovencous bypass, is a surgical treatment that involves the creation of an anastomosis between overloaded lymphatic vessels and neighboring venules near the location of the lymphatic obstruction [10]. This approach is associated with little surgical site morbidity, as the incisions are 1-2 cm in length, but it does require the presence of functioning lymphatic vessels [11]. Despite the benefits, both of these microsurgical techniques allow a volume reduction of less than 60%, thus requiring further improvement [12]. Moreover, these surgical approaches are recommended in the early-middle stages of the disease, as in later stages, LE is associated with extensive fibrosis and fat deposition [13]. A new device called BioBridgeTM (Fibralign Corporation, Union City, CA, USA) (Figure 1), made up of biocompatible aligned nanofibrillar collagen fibers mimicking a collagen matrix, could improve the benefits of these surgical strategies. BioBridgeTM consists of fibrils of type 1 porcine collagen, produced as ultrathin (1-2 um) membranes, and further integrated into thin mesh ribbons, with wide surface area and linked cavities, to reinforce soft tissue deficiencies [14].