Limb Salvage for "Hopeless" Lymphedema: Reviving the Charles Procedure
Kuldeep Singh, MD, Katherine Hawkins, MD, Michael Cooper, MD, Garry Lachhar, BS, Saqib Zia, MBBS, Jonathan Schor, MD, Jonathan Deitch, MD.
Staten Island University Hospital, Staten Island, NY, USA.
OBJECTIVES: The Charles procedure offers radical excision of lymphedematous tissue followed by skin grafting. This procedure is rarely offered, due to the potential for complications, but may provide excellent outcomes in improving quality of life. We describe our experience with a modified technique and a multi-disciplinary team approach in treating patients with advanced lymphedema.
METHODS: Seven patients with severe lower extremity lymphedema were treated with radical surgical excision. Patient demographics, operative details, and post-operative 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 (VAC) for initial dressings. Split-thickness skin grafting was performed 5-7 days post-operatively. All patients were managed with a predefined post-op care protocol.
RESULTS: Seven patients were referred to the clinic for evaluation of massive lower extremity lymphedema. There were four males and three females, with age range of 36-64 years. All patients had history of more than two 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); COPD 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. Post-operative complications included wound infection, requiring debridement or antibiotics, in four patients; re-admission for debridement in one patient; and reintubation post-operatively in one patient. Length of stay was an average of 27 days (range, 14 - 55 days).Patients were followed for an average of 15 months (range, 3 month - 3 years). All patients reported an improvement in quality of life post-operatively and had complete wound healing by final follow-up, without recurrence.
CONCLUSIONS: Although an underutilized 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.
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