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Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70 Page 9 of 13

A B

C D E

Figure 2. Charles procedure. A: pre-op photo of a patient with severe lymphoedema of the right leg; B: skin and subcutaneous tissue
removed from the right leg; C: tissue removed; D: after skin grafting; E: long term result

papillomatosis, hyperkeratosis, weeping dermatitis and chronic cellulitis are commonly seen in the distal
[64]
feet and toes . Such skin changes in the toes can be very uncomfortable for the patient, and many patients
[65]
may find it difficult to maintain personal hygiene. Karonidis et al. thought it advisable to preserve the
toes if there was only swelling without previous cellulitis or verrucous hyperkeratosis and neither deformity
nor osteomyelitis of the toes. Some surgeons have modified the original technique to preserve the deep
fascia to improve lymphatic drainage of the leg. When this procedure is selected for the right patient,
it results in considerable reduction in size, improvement in function and satisfactory results. However,
due to the poor cosmesis, associated bottleneck deformity and distal lymphoedema, this procedure is
[66]
not very commonly done. Van der Walt et al. applied negative pressure wound therapy after excisional
surgery to prepare the bed better for grafting. Negative wound pressure therapy is also commonly used
after applying the grafts to keep the grafts in place and for better take. The Charles procedure can be
associated with complications such as poor graft take, delayed healing, distal lymphoedema and recurrence
of lymphoedema, especially at the foot, which may need resurfacing, regrafting and toe amputations. The
patient needs to be taught good nail care and foot care, since infections in the nails can lead to repeated
cellulitis and worsening lymphoedema.

STAGED SUBCUTANEOUS EXCISION BENEATH SKIN FLAPS
[67]
This surgery is performed in two stages both over the medial and laterals aspect of the limbs . Usually
the medial aspect of the limb is removed first as more tissue can be removed. An incision is made over
the medial aspect of the limb. Flaps are raised on either side of the incision, and the excess tissue in the
subcutaneous area is removed. The excess skin can be closed, trimmed or de-epithelialised. This is then
repeated in the lateral aspect as well at least 3 months after the initial surgery.

CHARLES PROCEDURE ALONG WITH VASCULARISED LYMPH NODE FLAP (CHEN-MODIFIED
CHARLES PROCEDURE)
To reduce the risks associated with lymphoedema, such as repeated cellulitis and recurrence and
worsening of lymphoedema, VLNTs can be done along with the Charles procedure. While doing the
Charles procedure, the superficial veins are to be kept intact so that they can be used as a recipient vein