Excisional Procedures: Debulking Procedures

Concepts and Current Evidence

The concept of the excisional approach is removal of significant amounts of skin and subcutaneous tissue since the pathology of lymphedema is limited to these components. This approach serves to slow down the increase in fibroblasts, monocytes, adipocytes, and keratinocytes in the affected tissues. Moreover, reduction in limb size also serves to facilitate nonsurgical management by making it easier to fit compressive garments and clothes. Studies have shown that by decreasing the size of the affected limb, there is a decrease in the frequency of infections, which can eventually prevent further destruction of the lymphatics and subsequent disease progression. This technique is particularly useful in lower limb lymphedema, where it has shown an overall reduction of 52%, rather than upper limb lymphedema. Nevertheless, this technique can be used for the upper and lower limbs.

RRPP is based on an improved knowledge of the skin perforators, allowing for more radical excision techniques while still preserving perfusion to the angiosomes. Of the many excisional procedures available, RRPP has been proven to result in an acceptable, sustainable outcome. Additionally, the senior author (HCC) and colleagues have recently reported that the combination of vascularized lymph node transfer and modified RRPP in a one-stage procedure is safe and reliable and provides optimal outcomes for patients with advanced extremity lymphedema.

Indications for RRPP

• Patients with early- to mid-stage lymphedema (Hung Chi Chen-Stage IIIB patients) ( Table 23.1 )

  Table 23.1

  Hung-Chi Chen’s Staging for Lymphedema and Proposed Treatment.

  From Salgado CJ, Mardini S, Chen HC, et al. Ann Plast Surg . 2007;59:173–179.

  Stage		Proposed Treatment
  I	Sentinel decompensation stage; the lymphatic load exceeds lymphatic transport capacity, intralymphatic pressure builds, flow stagnates, and valvular incompetence occurs	Nonsurgical treatment
  II	Brief compensation phase; all lymphatic channels are recruited for drainage; dermal backflow, mild edema, and occasional erythema; patient is unaware with soft skin	Nonsurgical treatment or intermittent positive pressure pumping
  III	Fibroblasts, monocytes, adipocytes, and keratinocytes increase in the tissue, along with episodes of infection
  IIIA	Symptoms are obvious, but swelling can be improved after rest	Physiological procedures: lymph node transfer or lymphaticovenous anastomosis
  IIIB	Nonreversible changes are initiated	Lymph node transfer or RRPP with or without liposuction
  IVA	Fibrovascular proliferation, brawny leather-like skin, crypts, and cutaneous ulcers	Radical excision: Charles procedure with or without lymph node transfer
  IVB	Stage IVA + severely affected toes; repeated episodes of cellulitis, verrucous hyperkeratosis, deformity, or osteomyelitis	Charles procedure and toe amputation with or without lymph node transfer

  RRPP , Radical reduction and preservation of perforators.

• Patients in whom medical treatment has failed

• Patients not suitable for lymph node transfer only

• Occasionally, patients with advanced disease who are destined to undergo Charles procedure (but have a higher risk of potential complications)

• As an adjunct to other treatment modalities (e.g., lymph node flaps)

Preoperative Management

Bed rest, proper foot hygiene, and regular bathing are recommended for all lymphedema patients for 5 days prior to surgery to decrease postoperative complications. The affected extremity is measured on the morning of surgery and compared with tape measurements from the last office visit. If there is a significant increase (>20%), the surgery is postponed and compliance to preoperative preparation is reassured. Antibiotics (e.g., first-generation cephalosporins) are administered during anesthetic induction and continued for 3 days postoperatively.

Regional Anatomy

The blood supply to the medial and lateral skin parts of the lower limb originates from two or three of the following sources:

• On the medial aspect of the leg, the skin perforators from the posterior tibial artery are usually located at 9–12 cm, 17–19 cm, and 22–24 cm proximal to the medial malleolus.

• On the lateral aspect of the leg, most of the skin perforators are septocutaneous and are derived from the peroneal artery. These are the perforators that usually supply the skin paddle of the fibula osteocutaneous flap.

• As the medial and lateral skin flaps are bipedicle in design, there is blood supply from above the knee and below the ankle.

• On occasions, one of the two major perforators supplying the medial and lateral skin flap originates from the anterior tibial artery.

The blood supply to the medial and lateral skin of the upper limb is derived from one source in the arm and two sources in the forearm. The bipedicle design of the medial and lateral skin flaps ensures blood supply from above the elbow and below the wrist. The arm is nourished by septocutaneous or musculocutaneous perforators or by direct perforators arising from the brachial artery. The forearm is nourished by septocutaneous or musculocutaneous perforators or direct perforators arising from the radial, ulnar, and posterior interosseous arteries.

The radial artery gives off 9–17 fasciocutaneous branches, next to the radial recurrent artery, which arises near the origin of the radial artery. The superficial palmar arch arises just distal to the wrist. The ulnar artery, next to the anterior and posterior ulnar recurrent arteries and the common interosseous artery, gives off three to five fasciocutaneous branches running between the flexor carpi ulnaris and the flexor digitorum superficialis.