Limb Salvage for “Hopeless” Lymphedema: Reviving the Charles Procedure

Abstract

The Charles procedure offers radical excision of lymphedematous tissue followed by skin grafting. This procedure is rarely offered because of the potential for complications, but it may provide excellent outcomes in improving quality of life. We describe our experience with a modified technique and a multidisciplinary team approach in treating patients with advanced lymphedema. Seven patients with severe lower extremity lymphedema were treated with radical surgical excision. Patients’ demographics, operative details, and postoperative follow-up course were recorded. The operation entailed radical excision of the skin and lymphedematous tissues in a modified Charles procedure. The dissection was taken to the level of the fascia from the dorsal forefoot or ankle and continued to the knee or thigh, with wound vacuum-assisted closure for initial dressings. Split-thickness skin grafting was performed 5 to 7 days postoperatively. All patients were managed with a predefined postoperative care protocol. Seven patients were referred to the clinic for evaluation of massive lower extremity lymphedema. There were four men and three women, with age range of 36 to 64 years. All patients had history of >2 years of lifestyle-limiting swelling and recurrent bouts of cellulitis requiring hospitalization and intravenous antibiotic treatment. Six patients had chronic wounds of the affected legs due to skin breakdown, and three had significant disability in ambulation. Comorbid conditions included obesity (in five patients), hypertension (in four patients), chronic obstructive pulmonary disease or asthma (in three patients), depression (in three patients), and diabetes (in one patient). In the three patients with bilateral disease, intervention targeted the more severely affected limb. One patient in our series had disease confined only to the thigh. Postoperative complications included wound infection, requiring débridement or antibiotics, in four patients; readmission for débridement in one patient; and reintubation postoperatively in one patient. Length of stay was an average of 27 days (range, 14-55 days).Patients were observed for an average of 15 months (range, 3 month-3 years). All patients reported an improvement in quality of life postoperatively and had complete wound healing by final follow-up, without recurrence. Although it is an underused procedure, the Charles procedure presents a viable means of limb salvage for severe lymphedema. We present a multidisciplinary approach with excellent patient outcomes in a series of six patients.