Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures

Background: End-stage lower extremity lymphedema (LEL) poses a particularly formidable challenge to surgeons as multiple pathological processes are at work. Because single modality treatment is often unsuccessful, we devised a comprehensive multimodal surgical treatment. The aim of this study is to share the technical considerations and examine the clinical outcomes of this combined approach. Methods: Between 2013 and 2017, patients with International Society of Lymphology stage III, who underwent the combination treatment of Charles,’ Homan’s procedure with toe management and vascularized lymph node transfer (CHAHOVA), were included in this retrospective study. Outcomes evaluated were limb size, number of infectious episodes, compression garment usage, and rate of complications. Results: A total of 68 patients were included. With a mean follow-up of 29 months, the overall circumference reduction rate for the upper thigh and the rest of the extremity was 67.4% (48.2-88.2%) and 98.1% (88-100%), respectively. During the follow-ups, 2 (2.9%) patients experienced episodes of cellulitis and the average number of yearly infections decreased from 4.2 to 1.2 episodes per person. All patients were able to discontinue compression therapy without recurrence of lymphedema. Nine (13.2%) patients reported minor complications. Conclusion: The combine CHAHOVA in a single-stage procedure is an effective and safe approach in the end-stage LEL.