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Page 8 of 13 Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70

local anaesthetic, and liposuction is continued proximally. Finally, the proximal part of the arm is also
compressed. The incisions are left open to drain. The hand is rested on a large pillow at the level of the
heart. The next day, the dressings are replaced with compression garments.

After initial compression therapy, the garments need to be reassessed for loss of elasticity in the garment
and for reduction in the size of the limb. This is very important especially in the first 3 months after
surgery. The patient is assessed every 3 months for the first year to look out for change in the volume and
also to inspect the condition of the compression garments. Maximum reduction of limb size is usually
achieved in the upper limb at 3 months and in the lower limb at 6 months, but it may take longer. For
[57]
[58]
best results, it is advised to wear the garment lifelong . Hoffner et al. have shown a mean 5-year
postoperative reduction of 117% ± 26% in the limb with lymphoedema compared with the healthy arm.
SURGICAL DEBULKING
Surgical debulking of lymphoedema has been used for a long time. In spite of the popularity of surgical
debulking decreasing due to the introduction of microsurgical techniques, surgical debulking remains
the procedure of choice in carefully selected patients with Class III lymphoedema and skin changes,
lymphoedema secondary to filariasis and in places where a microsurgical facility is unavailable.

In patients with filariasis, the adult worms of Wuchereria bancrofti, Brugia malayi and Brugia timori invade
the lymphatic system and cause dilatation of the lymphatic channels, incompetence of the lymphatic valves
[59]
and obliteration of the lymphatic channels . This destruction of the lymphatic channels causes severe
oedema and fibrosis in the limbs with resultant skin changes such as warty outgrowths, acanthosis and
ulcers. When the limb and the toes become big, maintaining hygiene becomes difficult. This predisposes
to many fungal infections in the interdigital spaces and fissures in the feet. These fungal infections act as
[60]
entry points for many secondary bacterial infections, which produce acute dermatolymphangioadenitis .
Surveys estimate a frequency of 4.47 episodes of acute dermatolymphangioadenitis per year for bancroftian
[61]
filariasis and 2.2 episodes for brugian filariasis . Each episode of acute dermatolymphangioadenitis
worsens the lymphoedema and produces more fibrosis, scarring and more swelling. Destruction of the
lymphatic channels and severe fibrosis of the limbs precludes performing LVA and liposuction, respectively,
in such patients. Furthermore, many patients with filarial lymphoedema and severe lymphoedema have
many skin changes that are best treated by surgical debulking in the limbs. Microsurgical procedures such
as LVA and VLNTs are generally beneficial in the early stages of the disease, when the lymphatics are
relatively healthy and when the tissues are still soft and pliable. Chronic accumulation of lymphatic tissue
in the subcutaneous tissues cause thickening of the skin, hypercellularity, progressive fibrosis, increased fat
deposition and irreversible damage to the lymphatic vessels. For these patients with end-stage lymphatic
disease, excisional surgical procedures remain the mainstay of patient management. Large folds of skin
and subcutaneous tissue can be excised, which leads to improved outcomes. We will look at the different
excisional techniques in detail.

CHARLES PROCEDURE
[62]
The Charles procedure is the prototype of all excisional procedures . Although Sir Richard Henry
Havelock Charles who described the Charles procedure, described the technique mainly for lymphoedema
of the scrotum, the procedure bears his name for the excisional surgery for lymphoedema of the lower
[63]
limbs as a result of series of questionable references . The Charles procedure involves excision of the
skin, subcutaneous tissue and deep fascia of the legs involved with lymphoedema and grafting the raw
areas on the bare exposed muscle. This procedure is done in advanced lymphoedema with skin changes
[Figure 2A-E]. After excision of the skin, due to the unavailability of subdermal lymphatic drainage, worse
lymphoedema is expected distally in the foot. Severe secondary changes in the skin such as ulceration,