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Page 8 of 13 Yesantharao et al. Plast Aesthet Res 2022;9:60 https://dx.doi.org/10.20517/2347-9264.2022.67

breast to medical therapy time since with lymph
reconstruction lymphedema diagnosis node transfer
and not reported; mean and scaffold
lymphedema follow-up was 4 years placement
treatment with was effective
vascularized in achieving
lymph node sustained
transfer and volume
scaffold reduction,
placement reducing
infections, and
improving
patient
satisfaction

*See References section for full citation; citation number on References list provided here in parentheses. LVA: Lymphaticovenous anastomosis;
VLNT: vascularized lymph node transfer.

Nguyen et al. investigated delayed implantation of BioBridge scaffolds in secondary lymphedema patients
who had undergone prior lymphaticovenous anastomosis and/or vascularized lymph node transfer .
[35]
Included patients were largely stage 1 to stage 2 lymphedema patients with a unilaterally affected extremity,
who either had a suboptimal response to their initial physiologic procedure or desired further improvement
in their lymphedema symptoms. After scar release and liposuction, if indicated, BioBridge scaffolds were
tunneled subcutaneously to create a connection between intact native lymphatic tissue and the site of the
prior lymphaticovenous anastomosis or vascularized lymph node transfer. Patients in the BioBridge cohort
had a significantly greater reduction in the volume of the affected limb compared to historical controls
(111% vs. 70% edema reduction, respectively), with lymphatic mapping demonstrating evidence of
lymphangiogenesis and decreased dermal backflow in the BioBridge cohort. Furthermore, both surgical
subgroups (lymphaticovenous anastomosis and vascularized lymph node transfer) demonstrated positive
results with BioBridge placement, although a greater treatment response was noted in the vascularized
lymph node transfer group compared to the lymphaticovenous anastomosis group (7.6-fold versus 3.5-fold
increase in edema reduction, respectively). These successful results were sustained upon long-term follow-
up - more than 75% of patients who underwent BioBridge implantation maintained normal limb volumes at
an average of 29 months post-implantation.

Retrospective clinical investigations have studied secondary BioBridge placement in secondary lymphedema
patients with more advanced disease, intending to create treatment algorithms to optimize outcomes [36,37] .
Brazio et al. retrospectively reviewed outcomes of patients with stage II-III lymphedema undergoing
physiologic procedures versus liposuction, with downstream scaffold placement in some cases . They
[37]
found that patients with predominantly non-pitting lymphedema benefitted most from liposuction prior to
physiologic procedure/scaffold placement, while those with primarily pitting edema were best treated with
[37]
physiologic procedure first and liposuction as a possible second stage . Building on this study, Deptula et
al. investigated outcomes in late stage 2 to stage 3 secondary lymphedema patients who underwent prior
physiologic procedures to devise an algorithm that identifies ideal candidates for downstream BioBridge
placement . All included patients were treated with a proposed “triple therapy” involving initial debulking
[36]
with liposuction, followed by a physiologic procedure (lymphaticovenous anastomosis or vascularized
lymph node transfer) and then BioBridge placement. BioBridge placement as part of this “triple” therapy
was found to have the greatest impact in patients with persistent excess limb volume due to continued fluid
accumulation after lymphaticovenous anastomosis or vascularized lymph node transfer. In fact, BioBridge
placement in appropriately selected patients completely normalized limb volume in the affected extremity,
with sustained results noted at the two-year postoperative timepoint from the initial BioBridge placement.
Unlike standard debulking therapies such as liposuction alone, which require ongoing compression therapy
to prevent relapse, this triple therapy recreates lymphatic flow and thus allows patients to ultimately wean