Surgical Treatment of Lymphedema

Indications for Surgical Treatment

Indications for surgical intervention are impaired mobility secondary to extremity size and weight, recurrent episodes of cellulitis and lymphangitis, intractable pain, lymphangiosarcoma, and cosmesis. Operations for lymphedema are classified in two main categories: excisional operations and lymphatic reconstruction.

Excisional Operations

Excisional operations remove excess subcutaneous tissue to decrease the volume of the extremity. The subcutaneous lymphedematous tissue can be resected, or it can also be removed by liposuction. The most radical excisional operation is the Charles procedure. This operation removes the skin and all subcutaneous tissue from the anterior tibial tuberosity down to the malleoli. Skin grafts are subsequently applied. The main drawbacks of this procedure include sloughing of the skin grafts, excessive scarring, hyperkeratosis, and dermatitis.

Many staged operations have been described, mainly as modifications of the original Homans procedure. The mainstay of these operations involves the localized excision of the fibrotic subcutaneous tissue. Moderately thick flaps (1–1.5 cm) are elevated anteriorly and posteriorly to the midsagittal plane in the calf and/or thigh. The redundant skin is excised, and the wound is closed in one layer. Because not all of the edematous tissue is excised, most of these are palliative procedures and the results are directly related to the amount of subcutaneous tissue excised. The patients are susceptible to recurrences and must continue to wear elastic compression stockings.

The results of most of these procedures are good as far as volume reduction is concerned. Nonetheless, prolonged hospitalization, poor wound healing, large surgical scars, sensory nerve damage, and residual edema of the foot and ankle can be problems. These common complications limit such procedures to patients with disabling lymphedema that is not responding to maximal medical therapy. Results reported by the University of California at Los Angeles (UCLA) group under the leadership of Miller have been most satisfactory.

Brorson advocated liposuction as an alternative with good results. The logic of this procedure is that chronic lymphedematous tissue can be removed with liposuction techniques with good reduction of the size of the limb in a time period as short as 6 months.