# Lymphedema Surgical Treatment Using BioBridgeTM: A Preliminary Experience
## 4 Discussion
In rat models, a recent study looked at the potential of BioBridgeTM to both prevent and alleviate lymphedema. The restoration of lymphatic flow through the collagen scaffolds, in the presence of damaged and interrupted lymphatic channels, allows cellular organization along the graft, resulting in lymphatic regeneration, according to the authors, who speculate that the function of BioBridgeTM in directing capillary flow may be the initial promoter of lymphangiogenesis [19]. Furthermore, in the rat model, the drainage from the area with damaged lymphatics can be spontaneously repaired by the formation of new functional lymphatic channels, demonstrating that the positioning of BioBridgeTM concurrent with lymphadenectomy inhibits the development of lymphedema. This may present encouraging opportunities for cancer surgery. The use of collagen scaffolds to promote lymphangiogenesis in the surgical routine could improve the outcome of micro-surgical procedures in human subjects with lymphedema, with promising results, both in association with vascularized lymph-node transplantation and with venolymphatic anastomoses, leading to a reduction in the L-Dex bioimpedance index and the volume of the affected limbs [13]. Another study on rat models [31] utilized mature female Sprague Dawley rats, as the main objective of the models was to generate a situation that resembled the lymphedema condition in women, to assess the effect of BioBridgeTM scaffold implantation in prevention models and treatment models in animals submitted to radiation therapy. To reduce lymphedema in the rat LE model, [PERSON] et al. used a new propeller vascularized lymphatic tissue flap (pVLNT) in conjunction with BioBridgeTM [32]: after lymphadenectomy and radiation treatment, 15 female Sprague Dawley rats developed unilateral left hindlimb lymphedema. A skin tunnel was used to transmit an inguinal pVLNT from the unaffected groin to the contralateral groin. The flap was linked to four collagen threads, which were then fan-shaped and implanted beneath the skin of the hind limb. Group A (control), Group B (pVLNT), and Group C (pVLNT + CS) comprised the three study groups. Micro-computed tomography imaging was used to carry out a volumetric examination of both hindlimbs prior to surgery (at the first time point), as well as at 1 and 4 months after surgery. The relative volume difference (excess volume) was assessed for each animal. By using indocyanine green fluoroscopy, lymphatic drainage was evaluated for the quantity and morphology of new collectors as well as the time needed for ICG to travel from the injection point to the midline. The authors observed that a higher volume persisted in group A four months after lymphedema induction, but there was a considerable relative volume decline in groups B (\(-13.3\%\)) and C (\(-14\%\)). The viability of pVLNT and the functional repair of lymphatic channels in both the B and C groups was demonstrated by fluoroscopy. Only group C showed statistically significant increases in lymphatic pattern/morphology and lymphatic collector numbers. In human subjects, BioBridgeTM positioning seems to augment the size reduction of LE limbs compared to vascularized lymph node transplantation or venolymphatic anastomosis alone. To achieve a better outcome, [PERSON] et al. [33] proposed a triple-therapy surgical-treatment algorithm, that incorporated BioBridgeTM, for patients affected by LE stages II and III. First, liposuction debulking was used to treat patients with stage III lymphedema that had a mostly fibro-adipose component. After a year, patients received lymphatic mapping to look for any obstructed distal superficial lymphatics. If there was a history of cellulitis, patients with obstructed lymphatics were considered candidates for venolymphatic anastomosis with the addition of lymph node transplantation. Stage II patients with fibro-adipose tissue and fluid excess were treated first with a selective liposuction plus physiologic procedure. After surgery, the patients were monitored for 1-2 years to allow for equilibrium.