Excisional Procedures: Debulking Procedures

The excisional procedures aim to decrease the lymphatic load by removing the diseased tissue. In this chapter, we will describe the following excisional procedures: Radical reduction of lymphedema with preservation of perforators (RRPP), Chen-modified Charles procedures with vascularized lymph node flap transfers. The RRPP is based on an improved knowledge of the skin perforators, allowing for more radical excision techniques while still preserving perfusion to the angiosomes. The RRPP can also be combined with lymph node flap transfer to provide optimal outcomes for patients with advanced extremity lymphedema. Patients with primary or secondary advanced lower limb lymphedema with induration, fibrosis, brawny leather-like skin, ‘squared-off’ toes, hyperkeratosis and multiple fistulas can be treated most effectively using the Charles procedure. Potential complications of the traditional procedure are wound breakdown, hyperkeratosis, ulceration, and aggravation of foot lymphedema. To prevent these problems, many authors have described a modified Charles procedure. It is possible to improve the postoperative results, eliminating the risk of recurrence and the need for secondary operation, combining this procedure with a lymph node flap transfer. Chen-modified Charles procedure consists of the association of the traditional Charles Technique with the lymph node flap transfer. Additionally, liposuction can be used as a primary procedure or as an adjunct for lymphedema treatment to remove the hypertrophic subcutaneous adipose tissue.