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Chapter 48
General Principles
Gurusamy Manokaran
The debulking surgical procedure in lymphatic filariasis – lymphedema – is carried
out in grade IV lymphedemas with nodules, warty growths, and ulcers. The basic
principles in lymphedema surgery are (a) augment the lymphatic drainage using a
physiological procedure, and (b) reduce the lymphatic load by debulking the lymphedematous, lymph-producing surface. In this chapter, we will be talking about
our strategy for lymphedema surgery, followed by a review of the existing forms of
debulking surgery.
Our strategy for debulking is always done after establishing a lymphatic drainage
procedure, namely complete decongestive therapy (CDT) for 1 week, followed by a
permanent drainage surgical procedure, such as nodovenal shunt, lymphovenal
shunt, free omental transfer, or supramicrovascular surgery of transplanting a myo-
cutaneous flap with arterial, venous, and lymphaticolymphatic anastomosis. Once
permanent lymphatic drainage is established, the huge grade IV lymphedema with
or without skin changes shrinks, leaving only the subcutaneous fat, fibrous tissue,
and the soft tissues like muscle and fascia. We wait for 10–14 days and then debulk
the excess skin, fat, and subcutaneous tissue up to the level of the deep fascia under
tourniquet control. This debulking surgery may have to be done periodically at a
minimum interval of 6 weeks to 3 months, depending upon the entire size of the
limb, until near normal shape and size are achieved. We try to use the same skin to
resurface without using a split-thickness skin graft (STSG). The same remaining
skin with subcutaneous tissues containing the subdermal lymphatics drains the
reshaped limb and maintains the contour for a long time with a pressure garment,
leg elevation, elimination of the focus of sepsis, and prevention of secondary infection by periodic, cyclic antibiotics like penicillin, doxycycline, and quinolones (ciprofloxacin, ofloxacin, etc.), depending upon the sensitivity pattern of the drug and
patient.
1-16
G. Manokaran
Department of Plastic and Reconstructive Surgery and Lymphologist,
Apollo Hospitals, 21, Greams Road, Chennai, India
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_48, © Springer-Verlag London Limited 2011
399
400 G. Manokaran
The entire outcome of debulking surgery depends upon the methodical preoperative preparation and postoperative follow-up with the above-mentioned recommendations. If the patient does not follow the postoperative instructions meticulously,
secondary infection can occur. Secondary infection leading to lymphangitis and cellulitis is the main cause of recurrence and progress of lymphedemas. This abovementioned technique has been followed by us for the last 25 years, and we have
been able to achieve very good results and maintain the shape and size of the limb
in our long-term follow-ups. If any patient comes to us with recurrence or progress
of the lymphedema, we repeat a lymphoscintigram and find out the status of the
lymphatics, lymph nodes, and drainage. Most were found to have had repeated
attacks of lymphangitis due to their negligence and experienced recurrence. We
motivate these people again to meticulously follow the conservative, nonsurgical
methods like manual lymphatic drainage and CDT, by which most of the patients
get better and get back the original shape and size of the limb, and we maintain it
with a pressure garment or bandaging techniques. Very few patients (approximately
5–6%) need a revision surgical procedure, like redoing a nodovenal or lymphaticovenous shunt.
This debulking procedure is always done under tourniquet control to avoid blood
loss, hematoma, and infection. The tourniquet can be used safely for 2 h in the lower
limb and 1 h in the upper limb. Once the excision is made, the tourniquet is released
and perfect hemostasis secured before retaining the suction drain and closing the
wound in layers. The incision is always made as a reverse hockey stick on the medial
side of the limb. The edges of the skin surface are examined for viability after the
excess skin has been trimmed. We always try to go through the same scar for any
subsequent reduction surgeries so that patient does not have multiple unsightly scars
on the limbs. The excision always stops short of the deep fascia. We never open the
deep fascia because it allows the muscle to bulge into the subcutaneous plane and
makes wound closure difficult, causing a lot of pain during the postoperative period
and even blocking the drains.
The other debulking procedures that has been practiced for a long time is Charles
excisional surgery, wherein the lymphedematous tissue (skin, subcutaneous tissue up
to the fascia) is excised circumferentially and then STSG is done to cover the raw
area. As there is no subdermal plexus for drainage and the STSG is stuck to the fascia, it produces much worse edema distal to the excision, usually in the foot. Because
of the unaesthetic outcome and a bottle neck deformity, this procedure has almost
been abandoned these days. The Kondolean excision is also technically similar to the
Charles procedure; therefore, this technique has also almost been abandoned due to
the cobble stone appearance of the operated leg (unaesthetic appearance).
Thomson’s procedure was claimed to be a physiological procedure as the deepithelialized dermal flap is buried under the opposite skin flap and sutured in two
layers. The disadvantage of this procedure is that if the dermal flap sutured as a
deeper layer becomes necrosed, then the skin closure will not heal. Thus, we have
to re-open the flaps and salvage the necrosed skin flap and then provide skin cover.
This causes morbidity to the affected limb and it takes a longer time for the leg
wound to get settled.
48 General Principles
401
The older techniques of debulking surgeries such as the Thomson, Kondolean
and Charles procedures have been abandoned because of poor outcome. Many
patients are scared to undergo surgery after seeing this unsightly results. In many of
the centers where debulking surgery is performed for lymphedema, it is always carried out as a secondary procedure, following lymphatic drainage. These days simple
elliptical excisions of multiple stages, following a microvascular lymphatic drainage procedure, and maintained by conservative multimodality therapies like periodic antibiotics to prevent secondary infections, regular foot hygiene, CDT, and
pressure garments provide the most acceptable long-term results.
References
1. Miller TA. Charles procedure for lymphoedema: a warning. Am J Surg. 1980;139(2):
290-292.
2. Dumanian GA, Futrell JW. Radical excision and delayed reconstruction of a lymphoedema-
tous leg with a 15 year follow-up. Lymphology. 1996;29(1):20-24.
3. Revis Don R Jr. Lymphedema: treatment. http://www.lymphedemapeople.com.
4. Silkie. Complications of the Thompson’s procedure. www.Lymphoedemapeople.com/wiki
5. Kondoleon E. Die Operative Behandlung der elephantiastichen Oedeme. Zentralbl Chir.
1912;39:1022.
6. Servelle M. Surgical treatment of lymphedema: a report on 652 cases. Surgery. 1987;
101:484.
7. Sawhney CP. Evaluation of Thompson’s buried dermal flap operation for lymphoedema of the
limbs: a clinical and radioisotopic study. Br J Plast Surg. 1974;27:278-283.
8. Lee BB, Kim DI, Whang JH, Lee KW. Contemporary management of chronic lymphedema –
personal experiences. Lymphology. 2002;35(Suppl):450-455.
9. Huh SH, Kim DI, Hwang JH, Lee BB. Excisional surgery in chronic advanced lymphedema.
Surg Today. 2003;34:434-435.
10. Lee BB. Surgical management of lymphedema. In: Tredbar, Morgan, Lee, Simonian, Blondeau,
eds. Lymphedema—Diagnosis and Treatment. London: Springer; 2008:55-63, chap 6.
11. Lee BB, Kim YW, Kim DI, Hwang JH, Laredo J, Neville R. Supplemental surgical treatment
to end stage (stage IV –V) of chronic lymphedema. Int Angiol. 2008;27(5):389-395.
12. Auchincloss H. New operation for elephantiasis. Puert Rico J Publ Health Trop Med.
1930;6:149.
13. Dellon Al, Hoopes JE. The Charles procedure for primary lymphedema. Plast Reconstr Surg.
1977;60:589.
14. Homans J. The treatment of elephantiasis of the legs. N Engl J Med. 1936;215:1099.
15. Kim DI, Huh S, Lee SJ, Hwang JH, Kim YI, Lee BB. Excision of subcutaneous tissue and
deep muscle fascia for advanced lymphedema. Lymphology. 1998;31:190-194.
16. Sistrunk WE. Further experiences with the Kondoleon operation for elephantiasis. JAMA.
1918;71:800.
Chapter 49
Contemporary Indications and Controversies
Byung-Boong Lee, James Laredo, and Richard F. Neville
Chronic lymphedema was once considered to be a relatively benign condition of
limb swelling associated with minimal morbidity. However, this old concept has
been proven to be totally erroneous; the condition is steadily progressive and
affects not only the lymphatic system itself, but also the entire surrounding
soft tissue, resulting in a unique condition of clinically significant dermato
lipofibrosclerosis.
Once chronic lymphedema progresses to its end stage (stages IV–V, equivalent to
International Society of Lymphology (ISL) stage III),
of complex decongestive therapy (CDT)
the soft tissue reduces the efficacy of CDT and the massively swollen limb becomes
increasingly difficult to wrap properly with compression bandaging. The extremity is
often grotesquely disfigured with a severely deformed contour (Fig. 49.1).
Chronic lymphedema becomes a disabling and distressing condition that is unresponsive to CDT. This results in frequent bacterial and fungal infections in a limb
with a chronic inflammatory condition affecting the skin and soft tissue.
Once the local/regional sepsis begins, the risk of systemic sepsis is increased and
may become a potentially life-threatening condition. The chronic inflammation
associated with lymphedema also predisposes patients to an immunodeficiency
and wasting condition resulting in malignancies such as Kaposi sarcoma and
lymphangiosarcoma.
The associated morbidity and potentially serious complications of chronic lymphedema have significant physical, psychological, social, and financial burdens that
have an impact on patients’ lives, resulting in poor quality of life in the advanced
stage.4 Hence, a new treatment regimen was desperately needed in an effort to
prevent such a disastrous outcome.
1,2
3,4
5,6
is curtailed substantially. The fibrosis of
the effectiveness and efficacy
7,8
B.-B. Lee (*)
Department of Surgery, Division of Vascular Surgery,
George Washington University School of Medicine,
Washington, DC, USA
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_49, © Springer-Verlag London Limited 2011
403
404 B.-B. Lee et al.
Fig. 49.1 Clinical appearance of the bilateral
lower limbs with chronic lymphedema at its
end stage (clinical stage III to IV) before the
excisional surgery. The resection of
grotesquely disfigured fibro-edematous tissue
was mandated to improve complex
decongestive therapy (CDT)-based
management
As part of a new approach to the treatment of chronic lymphedema, various excisional surgeries were revisited during the last decade to reassess their potential role
as a new treatment.
7-9
Careful review determined that the poor outcomes associated
with excisional surgery throughout the last century was mostly due to a cavalier
approach by surgeons, a lack of appropriate knowledge about lymphedema and
lymphatic function, and improper indications.
Excisional surgery,
10-13
once condemned by many surgeons because of severe
postoperative morbidity, now has been resurrected with limited use among patients
with end-stage chronic lymphedema with strictly controlled indications. However,
many remain skeptical and biased against excisional surgery based on previous
experiences of it as a sole independent therapy.
Excisional surgery plays an auxiliary role in supplementing failing CDT. The reduction and excision of fibrosclerotic, overgrown soft tissue improves the efficacy of subsequent CDT and compression bandaging. In addition, there is no more risk of injury to
the remaining salvageable lymphatic vessels by the excision procedure at this advanced
stage.9 For example, excisional surgery may be performed in a patient with intractable
end-stage lymphedema associated with recurrent local and systemic sepsis that is refractory to maximum CDT combined with compression therapy. The outcome of excisional
surgery is dependent on the appropriate postoperative CDT and patient compliance.
7-9
Clinical Experience
A total of 1,065 patients (131 men and 934 women; 259 primary lymphedemas and
806 secondary lymphedemas; age range, 2 months to 82 years) were assessed
between January 1995 to December 2004 with various noninvasive tests, including
lymphoscintigraphy, to determine proper clinical and laboratory staging.
14
49 Contemporary Indications and Controversies
405
Twenty-two patients (mean age, 46 years; three men, 19 women; five primary
lymphedemas and 17 secondary lymphedemas) at stage IV or advanced stage III
underwent excisional surgery on 33 limbs (11 unilateral; 22 bilateral) as supplemental therapy; indications were for palliation, to reinforce failing CDT, to improve the
local condition to facilitate proper CDT and/or compression therapy, and to reduce
the incidence of sepsis.
Indications for excisional surgery as an additional/supplemental therapy
9,14
:
Failure to implement proper care with the CDT at clinical stage III or IV (end •
stage)
Progression of the disease to end stage, despite maximal treatment for a minimum •
of 2 years and declared a “treatment failure” by a multidisciplinary care team
Increased frequency and/or severity of local and/or systemic sepsis•
Treatment failure and subsequent progression of the disease despite maximal •
therapy for 2 years and properly declared per recommendation by IRB to become
a candidate for excisional surgery
Evaluation confirmed end-stage chronic lymphedema (stage IV or late stage III)
with increased difficulty in providing effective CDT and increased frequency and
severity of local and/or systemic sepsis (3–4 episodes per year) despite prophylactic
antibiotic administration.
A modification of Auchincloss-Homan’s operation
15,16
was used to excise a generous amount of grotesquely disfigured tissue with advanced dermato-lipo-fibrosclerotic change, including the whole skin layer, subcutaneous tissue, and muscle
fascia in order to re-establish the normal limb contour and to allow proper postoperative compression therapy (Fig. 49.2).
Fig. 49.2 Clinical appearance of the bilateral
lower limbs with fully restored normal contour
following excisional surgery. The efficacy of
CDT was markedly improved postoperatively
406 B.-B. Lee et al.
Postoperative MLD and compression therapy were performed in all patients.
Pre- and postoperative evaluation were based on clinical improvement (patient satisfaction index), four-level limb circumference measurements, infrared optical limb
volume determination, and lymphoscintigraphy.
7-9
Follow-up assessment was made every 6 months for a mean of 4 years. An additional clinical evaluation was performed during each episode of local and/or systemic sepsis.
At 12 months, 28 out of the 33 limbs in 22 patients with good compliance in
maintaining postoperative compression therapy reported satisfactory improvement.
At 24 months, 18 out of 28 limbs with good compliance were able to maintain
successful results while 10 with poor compliance failed.
At 48 months, 8 limbs in 6 patients were compliant and maintained satisfactory
improvement. Among the remaining 25 limbs, 9 were lost to follow-up and 16 noncompliant patients experienced further deterioration.
Our own experience has shown that excisional surgery is a very effective method
of establishing optimal conditions for CDT. Patients report satisfactory improvement initially, but most do not experience long-term improvement without postoperative CDT and/or compression therapy.
Satisfactory clinical improvement following surgery showed that patient compliance with postoperative CDT was once again confirmed as the single most important
factor that determined long-term outcome. Compliant patients maintained successful
results, whereas noncompliant patients experienced further deterioration.
Compliance of the patient and the commitment to life-long CDT are crucial in
order to achieve satisfactory long-term results among our candidates. Full integration with CDT-based therapy as a part of a multidisciplinary team approach following surgical therapy is the only means of achieving the most effective control of
chronic lymphedema.
Excisional surgery plays a new supplemental role in the non- to poorly- responding CDT group of chronic lymphedema patients. As adjunctive therapy in most situations, together with CDT it plays a critical role in the management of chronic
lymphedema. Surgery and CDT have mutually complementary effects.
At the present time, CDT-oriented treatment is still first-line therapy, although it
is not curative. It effectively prevents disease progression and produces a satisfactory outcome in the majority of chronic lymphedema patients who are compliant
and maintain self-motivated home treatment following hospital-initiated care.
Patient compliance with maintenance CDT is the most important factor in the treatment of chronic lymphedema. Prevention and treatment of systemic and/or local
infection (e.g., cellulitis, erysipelas) is the next most important factor in the successful management of chronic lymphedema with this combined approach, with excisional surgery reserved for end-stage disease.
17
Based on the same principle, percutaneous liposuction was introduced as a less
radical surgical approach to avoid the complications and morbidity associated with
the traditional excisional technique.
18,19
Instead of resecting all soft tissue with fibrosclerotic overgrowth using a conventional open surgical method, liposuction aims to remove excessive adipose tissue alone
49 Contemporary Indications and Controversies
407
in order to obliterate the epifascial compartment by “circumferential” suction-assisted
lipectomy. This technique, however, requires more vigorous compression therapy following the procedure to maintain the reduced limb volume.
Initial results of liposuction to remove excessive adipose tissue in the early stage
of lymphedema have been reported, with excellent long-term results, despite lingering doubt regarding the risk of damage to the remaining lymphatic system.
This new approach remains to be proven. Its efficacy, long-term results, durability, and safety remain to be determined. The effect of liposuction and the risk of
collateral damage to the viable lymph vessels are still unclear.
Conclusion
Excisional surgery is a viable option as supplemental therapy in the treatment of
intractable lymphedema at its end stage by improving the postoperative CDT in
order to break the vicious cycle of deteriorating CDT and increasing sepsis. Longterm maintenance of satisfactory clinical improvement following excisional surgery
is totally dependent on patient compliance with maintenance postoperative CDT/
compression therapy.
References
1. Olszewski WL. Episodic dermatolymphangioadenitis (DLA) in patients with lymphedema of
the lower extremities before and after administration of benzathine penicillin: a preliminary
study. Lymphology. 1996;29:126-131.
2. Lee BB. Chronic lymphedema, no more stepchild to modern medicine! Eur J Lymphology.
2004;14(42):6-12.
3. Lee BB. Classification and staging of lymphedema. In: Tredbar LL, Morgan CL, Lee BB,
Simonian SJ, Blondeau B, eds. Lymphedema—Diagnosis and Treatment. London: Springer; 2008:
21-30, chap 3.
4. Lee BB, Bergan JJ. New clinical and laboratory staging systems to improve management of
chronic lymphedema. Lymphology. 2005;38(3):122-129.
5. Casley-Smith JR, Mason MR, Morgan RG, et al. Complex physical therapy for the lym-
phedematous leg. Int J Angiol. 1995;4:134-142.
6. Hwang JH, Kwon JY, Lee KW, et al. Changes in lymphatic function after complex physical
therapy for lymphedema. Lymphology. 1999;32:15-21.
7. Lee BB, Kim DI, Whang JH, Lee KW. Contemporary management of chronic lymphedema –
personal experiences. Lymphology. 2002;35(Suppl):450-455.
8. Lee BB. Current issue in management of chronic lymphedema: personal reflection on an expe-
rience with 1065 patients. Lymphology. 2005;38:28.
9. Lee BB, Kim YW, Kim DI, Hwang JH, Laredo J, Neville R. Supplemental surgical treatment
to end stage (stage IV –V) of chronic lymphedema. Int Angiol. 2008;27(5):389-395.
10. Homans J. The treatment of elephantiasis of the legs. N Engl J Med. 1936;215:1099.
11. Sistrunk WE. Further experiences with the Kondoleon operation for elephantiasis. JAMA.
1918;71:800.
12. Kinmonth JB, Patrick J II, Chilvers AS. Comments on operations for lower limb lymphedema.
Lymphology. 1975;8:56-61.
408 B.-B. Lee et al.
13. Dellon Al, Hoopes JE. The Charles procedure for primary lymphedema. Plast Reconstr Surg.
1977;60:589.
14. Lee BB. Surgical management of lymphedema. In: Tredbar LL, Morgan CL, Lee BB, Simonian SJ,
Blondeau B, eds, Lymphedema-Diagnosis and Treatment. London: Springer; 2008: 55-63,
chap 6.
15. Auchincloss H. New operation for elephantiasis. Puerto Rico J Publ Health Trop Med.
1930;6:149.
16. Huh SH, Kim DI, Hwang JH, Lee BB. Excisional surgery in chronic advanced lymphedema.
Surg Today. 2003;34:434-435.
17. Lee BB, Andrade M, Bergan J, et al. Diagnosis and treatment of primary lymphedema.
Consensus document of the International Union of Phlebology (IUP)-2009. Int Angiol.
2010;29(5):454-470.
18. Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces
arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr
Surg. 1998;102(4):1058-1067; discussion 1068.
19. Brorson H, Svensson H, Norrgren K, Thorsson O. Liposuction reduces arm lymphedema without
significantly altering the already impaired lymph transport. Lymphology. 1998;31(4):156-172.