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Long-Term Follow-Up After the Charles Procedure: Possibilities for Minimally Invasive Reconstructive Lymphedema
Natalia Ewa Krzesniak1, Marzanna Zaleska2,3, Balazs Mohos4,5
1Department of Plastic and Reconstructive Surgery, Centre of Postgraduate Medical Education, Prof. W. Orlowski Memorial Hospital, Warsaw, Poland.
Insights
The Charles procedure (CP) can lead to long-term lymphedema complications. Minimally invasive lymphaticovenous anastomosis (LVA) surgery offers relief for persistent swelling after CP, improving patient quality of life.
Area of Science:
- Vascular Surgery
- Lymphedema Management
- Microsurgery
Background:
- The Charles procedure (CP) is a radical surgical option for advanced lymphedema, but often results in significant long-term complications.
- Patients undergoing CP may experience persistent or recurrent lower extremity lymphedema, impacting quality of life and requiring ongoing management.
- Complications include social stigma, need for lifelong compression, distal lymphedema, fibrosis, and inflammation, prompting further surgical interventions.
Abstract:
The Charles procedure (CP) is a potentially devastating treatment; however, in cases of an end stage of untreated or improperly treated lymphedema, it is the ultimate surgical therapy. As a life-saving solution, it quickly relieves patients with giant, hypertrophic extremities, mostly in ambulation and hygiene maintenance. Nevertheless, long-term results may disappoint both doctors and patients, who struggle with social stigma, the need for lifelong compression, massive lymphoedema in the distal parts of the feet, badly fitting shoes, excessive skin fibrosis, severe keratinization of skin-grafted surfaces, periodic lymphorrhea from the resected areas, or acute and chronic inflammation. For these reasons, patients may seek further surgical help, even many years after treatment. This article describes findings in fluorescent lymphography with indocyanine green (ICG-L) in four patients (49, 56, 56 years old females and 35 years old males) after CP and outcomes of treatment with lymphaticovenous anastomosis (LVA). In all patients, nonresected areas of the dorsum of the feet showed massive lymphedema stage II to III with dermal backflow (DB). In two patients, resected and skin-grafted areas showed deep subfascial lymphatics with lazy flow and no DB. In the remaining two cases, resected areas showed massive DB. Patients were reluctant to undergo further extensive surgical treatment with lymph node transfers due to the trauma experienced after CP. Since they still struggle with residual lower extremity lymphedema in unresected areas of the lower limbs, we performed minimally invasive, physiologic LVA surgeries in their feet, and in one patient in proximal thighs. In all cases, the postoperative course was uneventful. The treatment brought relief, reducing the circumference of the feet by ~2 cm, and allowed the return to previously used shoes in a follow-up of 18-36 months. This is the first report of ICG-L findings in CP patients, who benefit from minimal invasive LVA surgery. This information might help improve the life quality of patients after CP.
