Limited Segmental Resection of Symptomatic Lower-Extremity Lymphodystrophic Tissue In High-Risk Patients

Tanya M. Oswald, MD, William Lineaweaver, MD

Disclosures

South Med J. 2003;96(7) 

In This Article

Abstract and Introduction

In obese patients, lymphodystrophic tissue can create large masses that are microscopically indistinguishable from chronic lymphedema. This tissue can be disabling, especially in the lower extremities. The tissue is refractory to conservative therapy and is prone to cellulitis and abscess formation. The patients are regarded as being at high risk for surgical complications due to obesity and related illnesses. We report two cases of patients with lesions severely limiting walking. The two patients weighed 490 and 520 lb, respectively. One patient had hypertension and asthma; the other had arrhythmias and chronic venous thrombosis. One patient had wedge resection of the right groin (23 lb) and knee (5 lb), and the second patient had resection of the right thigh (65 lb) and left thigh (84 lb). All procedures were done separately. Both patients reported improvement in walking. Simple wedge excision was an effective, minimally complicated treatment for these patients.

Resection of lymphedematous tissue has evolved over the last century. Earlier approaches are epitomized by the so-called Charles procedure, which was originally applied to scrotal elephantiasis, but has now come to be defined as a procedure of the lower extremity.[1] This operation consists of resecting all skin and subcutaneous tissue in the affected part, harvesting the skin as split-thickness grafts from the surgical specimen, and applying these grafts to the fascia underlying the level of resection. Although functional results can be achieved with this approach, disfigurement and complications have been a prominent deterrent to consistent use of this operation.[1,2]

Homans[3] introduced the concept of preserving the skin overlying the lymphedematous subcutaneous tissue as flaps and using these skin flaps to cover the sites of resection. Fonkalsrud and Coulson[4] and Feins et al[5] developed this concept for treatment of lymphedema in children. Miller et al[6] labeled this procedure "staged skin and subcutaneous excision for lymphedema" and reported good long-term results in adult patients.[1,6] In their operation, lymphedematous legs are reduced in stages, starting with a medial resection. After healing, the lateral aspects of the limb are reduced, and further procedures are done as necessary.

The procedures using subcutaneous resection of skin flap coverage offer a real advance in control of leg swelling and preservation of full-thickness skin flap coverage with acceptable appearance. The procedures, however, are extensive and require multiple operations, all of which are followed by prolonged periods of bed rest. Adult patients with significant medical complications may be reluctant to undertake such an involved surgical course with total extremity recontouring as an endpoint, and their surgeons may share this reluctance.

We have recently treated patients with lymphedema and/or lipodystrophy, who have had significant medical problems and localized complaints related to specific areas of their disordered tissue. In such cases, segmental resection of tissue related to the patient's complaints was undertaken with functional improvement as a goal. We present two patients who illustrate this approach. Patient data and medical complications are outlined in Table 1 . Details of the surgeries are summarized in Table 2 .

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