Radical reduction of lymphedema with preservation of perforators

Surgical management of lymphedema of the lower extremity is indicated in select patients when conservative measures have failed. The excisional approach has traditionally consisted of a staged excision procedure or total excision of diseased tissue. Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators (RRPP) applies an excisional approach and microsurgical principles to the radical reduction of lymphedema.

Fifteen patients underwent RRPP during the period of June 1993 to February 2002 and were included in this study. Medial and lateral skin flaps were raised through incisions on the anterior and posterior leg, preserving a 4-cm skin bridge in the central portion of the incisions. The skin flaps were reduced to 5 mm in thickness, except in the vicinity of the lateral and medial septae, which contain perforators from the posterior tibial and peroneal arteries.

At an average follow-up period of 13 months, a statistically significant reduction in lymphedema was achieved (P < 0.05). The average percentage in reduction above the knee was 51%, below the knee 66%, at the ankle 44%, and at the level of the foot 41%. The average overall lymphedema reduction for the patients was 52%. There were no cases of wound breakdown or skin flap necrosis. Complications consisted of cellulitis in 3 patients and seroma and hematoma in 1 patient.

Based on angiosome principles and application of perforator principles to the surgical reduction of lymphedema, effective, long-lasting, and cosmetically appealing results are achieved in a single-stage procedure.