Excisional Procedures: Debulking Procedures

Key Points

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Treatment of advanced lymphedema remains a challenge in reconstructive surgery. Surgical management with excisional procedures is indicated in select patients when conservative measures have failed.
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Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators applies an excisional approach and microsurgical techniques to the radical reduction of lymphedema.
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Chen-modified Charles procedure consists of the association of the traditional Charles Technique with the lymph node flap transfer. Chen-modified Charles procedure prevents potential complications of the traditional technique, such as recurrent infection and aggravation of the lymphedema. Additionally, the toe treatment is an important part of the treatment of advanced lymphedema to prevent cellulitis.

Introduction

Lymphedema refractory to nonoperative management may require surgical procedures. There are several different surgical approaches to the treatment of lymphedema. Classically, the surgical methods are categorized as physiological and excisional procedures. Physiological procedures attempt to restore or improve lymphatic flow, whereas excisional procedures aim to decrease lymphatic load by removing the diseased tissue. However, all of these procedures have common aims: to improve limb size and decrease the incidence of cellulitis, and thus improve the patient’s quality of life.

In this chapter, we will describe the following excisional procedures:

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Radical reduction of lymphedema with preservation of perforators (RRPP)
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Chen-modified Charles procedure with vascularized lymph node flap transfers

We will also discuss the role of liposuction in lymphedema.

Radical Reduction of Lymphedema with Preservation of Perforators

Concepts and Current Evidence

The concept of the excisional approach is removal of significant amounts of skin and subcutaneous tissue since the pathology of lymphedema is limited to these components. This approach serves to slow down the increase in fibroblasts, monocytes, adipocytes, and keratinocytes in the affected tissues. Moreover, reduction in limb size also serves to facilitate nonsurgical management by making it easier to fit compressive garments and clothes. Studies have shown that by decreasing the size of the affected limb, there is a decrease in the frequency of infections, which can eventually prevent further destruction of the lymphatics and subsequent disease progression. This technique is particularly useful in lower limb lymphedema, where it has shown an overall reduction of 52%, rather than upper limb lymphedema. Nevertheless, this technique can be used for the upper and lower limbs.

RRPP is based on an improved knowledge of the skin perforators, allowing for more radical excision techniques while still preserving perfusion to the angiosomes. Of the many excisional procedures available, RRPP has been proven to result in an acceptable, sustainable outcome. Additionally, the senior author (HCC) and colleagues have recently reported that the combination of vascularized lymph node transfer and modified RRPP in a one-stage procedure is safe and reliable and provides optimal outcomes for patients with advanced extremity lymphedema.

Indications for RRPP

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Patients with early- to mid-stage lymphedema (Hung Chi Chen-Stage IIIB patients) ( Table 23.1 )

Table 23.1

Hung-Chi Chen’s Staging for Lymphedema and Proposed Treatment.

From Salgado CJ, Mardini S, Chen HC, et al. Ann Plast Surg . 2007;59:173–179.

Stage		Proposed Treatment
I	Sentinel decompensation stage; the lymphatic load exceeds lymphatic transport capacity, intralymphatic pressure builds, flow stagnates, and valvular incompetence occurs	Nonsurgical treatment
II	Brief compensation phase; all lymphatic channels are recruited for drainage; dermal backflow, mild edema, and occasional erythema; patient is unaware with soft skin	Nonsurgical treatment or intermittent positive pressure pumping
III	Fibroblasts, monocytes, adipocytes, and keratinocytes increase in the tissue, along with episodes of infection
IIIA	Symptoms are obvious, but swelling can be improved after rest	Physiological procedures: lymph node transfer or lymphaticovenous anastomosis
IIIB	Nonreversible changes are initiated	Lymph node transfer or RRPP with or without liposuction
IVA	Fibrovascular proliferation, brawny leather-like skin, crypts, and cutaneous ulcers	Radical excision: Charles procedure with or without lymph node transfer
IVB	Stage IVA + severely affected toes; repeated episodes of cellulitis, verrucous hyperkeratosis, deformity, or osteomyelitis	Charles procedure and toe amputation with or without lymph node transfer

RRPP , Radical reduction and preservation of perforators.

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Patients in whom medical treatment has failed
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Patients not suitable for lymph node transfer only
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Occasionally, patients with advanced disease who are destined to undergo Charles procedure (but have a higher risk of potential complications)
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As an adjunct to other treatment modalities (e.g., lymph node flaps)

Preoperative Management

Bed rest, proper foot hygiene, and regular bathing are recommended for all lymphedema patients for 5 days prior to surgery to decrease postoperative complications. The affected extremity is measured on the morning of surgery and compared with tape measurements from the last office visit. If there is a significant increase (>20%), the surgery is postponed and compliance to preoperative preparation is reassured. Antibiotics (e.g., first-generation cephalosporins) are administered during anesthetic induction and continued for 3 days postoperatively.

Regional Anatomy

The blood supply to the medial and lateral skin parts of the lower limb originates from two or three of the following sources:

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On the medial aspect of the leg, the skin perforators from the posterior tibial artery are usually located at 9–12 cm, 17–19 cm, and 22–24 cm proximal to the medial malleolus.
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On the lateral aspect of the leg, most of the skin perforators are septocutaneous and are derived from the peroneal artery. These are the perforators that usually supply the skin paddle of the fibula osteocutaneous flap.
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As the medial and lateral skin flaps are bipedicle in design, there is blood supply from above the knee and below the ankle.
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On occasions, one of the two major perforators supplying the medial and lateral skin flap originates from the anterior tibial artery.

The blood supply to the medial and lateral skin of the upper limb is derived from one source in the arm and two sources in the forearm. The bipedicle design of the medial and lateral skin flaps ensures blood supply from above the elbow and below the wrist. The arm is nourished by septocutaneous or musculocutaneous perforators or by direct perforators arising from the brachial artery. The forearm is nourished by septocutaneous or musculocutaneous perforators or direct perforators arising from the radial, ulnar, and posterior interosseous arteries.

The radial artery gives off 9–17 fasciocutaneous branches, next to the radial recurrent artery, which arises near the origin of the radial artery. The superficial palmar arch arises just distal to the wrist. The ulnar artery, next to the anterior and posterior ulnar recurrent arteries and the common interosseous artery, gives off three to five fasciocutaneous branches running between the flexor carpi ulnaris and the flexor digitorum superficialis.

Surgical Design and Techniques for RRPP

The patient is placed in a supine position on the operating table. A pneumatic tourniquet is placed as proximally as possible on the extremity.

In the lower limb, the markings on the leg consist of two anterior and two posterior ellipses positioned obliquely and parallel to the each other. The elliptical markings serve two purposes: They allow for skin excision without dog-ears and provide good access to the subcutaneous layer around the circumference of the leg ( Fig. 23.1 ).

The incisions are placed at the junction between two angiosomes, notably those of the posterior tibial and peroneal arteries. Posteriorly, the incision is made between the two heads of the gastrocnemius muscle. Skin incisions are linear and oriented vertically, and a skin bridge with a minimum width of 4 cm separates the ellipses to avoid circulation compromise to the central part of the skin flap.

Perforating skin vessels from the posterior tibial and peroneal arteries are mapped with a handheld Doppler probe above the levels of the medial and lateral malleoli, respectively. Commonly, these perforators are located within a 12×3 cm (axial-transverse) rectangle above the medial and lateral malleoli. In the middle of the leg, one large perforator is identified on the medial and lateral sides, supplying the medial and lateral skin flaps, respectively. The normal diameter of these perforators ranges from 1 to 3 mm for both artery and vein. Two centimeters of fascia and fat is preserved around the two main perforators in the medial and lateral skin flaps. If several large perforators are found, the one located close to the center and farthest from the preserved medial and lateral tissue over the malleoli is marked.

The ellipse represents the area of the skin that will be excised after preservation of skin perforators. The subcutaneous fat is tangentially excised until the skin flap is approximately 5 mm thick, preserving the subdermal venous plexus and minimal subdermal fat. The size of these ellipses depends on the size of the leg and the expected amount of debulking procedure. The leg is partially exsanguinated, which allows for better visualization of the perforators to the skin. The incisions are made down to the level of the deep fascia overlying the muscle compartments. All layers above this fascia are elevated as one unit, on both the medial and lateral aspects of the leg.

Care is taken to preserve the superficial peroneal nerve and the sural nerve. The subcutaneous tissue and skin around the medial and lateral malleoli are left untouched. The tourniquet is deflated, and hemostasis is performed. The viability of the skin flaps is assessed. The skin ellipses, along with underlying subcutaneous fat, are then excised. The resultant wound edges are approximated to see if further skin excision is possible. If not, suction drains are introduced and the wounds are closed.

In the upper limb, the first incision is placed between the angiosomes of the radial artery and the ulnar artery. Posteriorly, an incision is also made between the two angiosomes. A line is drawn from 1 cm below the center of antecubital fossa to the tubercle of the scaphoid on the volar forearm. This surface marking represents the radial artery and anterolateral intermuscular septum. A second line is drawn from the medial epicondyle of the humerus to the lateral edge of the pisiform. The ulnar artery also commences from 1 cm below the center of the antecubital fossa to a point on the second line that is at the junction between the proximal and middle thirds. From this point on the second line, the ulnar artery continues to the pisiform. The markings of the flap consist of an anterior and a posterior ellipse with a 30° angle to minimize dog-ears and preserve the central skin bridge. The anterior (on the volar aspect) ellipse is designed between the surface anatomical lines corresponding to the radial and ulnar arteries, preserving their major septocutaneous branches. The presence of radial and ulnar arteries is confirmed by using a handheld Doppler probe. The posterior (dorsal aspect) ellipse is designed at the central area along the axis of the forearm. If a debulking procedure of the arm is required, an ellipse is designed along the medial aspect, as there is usually more redundant tissue and the resulting scar is less conspicuous, providing a better cosmetic result. The size of the ellipse depends on the size of the extremity and the expected amount of resection after the debulking procedure.

Care is taken to preserve the medial and lateral cutaneous nerves of the forearm, particularly the cutaneous branch of the ulnar nerve around the elbow. The vascular branches are identified during elevation of the medial and lateral skin flaps.

The areas on the medial and lateral aspects of the forearm, around the wrist, are left untouched. The incisions are made down to the deep fascia. All the tissue layers above the fascia are elevated, and the procedure is carried out in the same manner as already described. The large veins are preserved as much as possible.

Postoperative Care

Postoperative dressings include an inner loose elastic bandage and an outer tight, compressive elastic bandage. The outer bandage is removed 2 hours after the procedure in the postanesthesia recovery unit. Patients usually remain in the hospital for 3–5 days and are then discharged, with the recommendation to use a compression stocking and to elevate the extremities for the next 2 weeks.

Outcomes

In our experience, there is minimal operative morbidity or complications requiring operative intervention. Overall, extremity reduction was statistically significant when pre- and postoperative measurements were compared with the unaffected contralateral limb.

In the lower limb, the average percentage of circumferential reduction for all patients above the knee was 51%; below the knee, 66%; at the ankle, 44%; and at the level of the foot, 41%. The overall circumferential reduction for the lower limb lymphedema was 52%. Complications consisted of cellulitis in 20% of the patients who received RRPP without other procedures, seroma in 6.7%, and hematoma in 6.7%. There was no incidence of wound breakdown or skin flap necrosis. In 13.3% of the patients, there were complaints of numbness in the extremity, which had not resolved within a year. Most patients complained of a transient numbness of the leg that resolved within 6 months.

For the upper limb, the average circumferential reduction above and below the elbow, at the wrist, and at the hand were 15.1%, 20.7%, 0.5%, and 3.6%, respectively. Statistical analysis showed significant circumference reduction above and below the elbow but not at the wrist and hand. There were no cases of wound breakdown, skin necrosis, or cellulitis in the postoperative period. Mild numbness confined to the vicinity of the surgical incisions was a complaint in 36.3% of the patients. All lymphedema reductions were completed in one stage ( Fig. 23.2A–C ).