Limited segmental resection of symptomatic lower-extremity lymphodystrophic tissue in high-risk patients. (Case Report).

Abstract: In obese patients, lymphodystrophic tissue can create large masses that are microscopically indistinguishable from chronic lymphedema. This tissue can be disabling, especially in the lower extremities. The tissue is refractory to conservative therapy and is prone to cellulitis and abscess formation. The patients are regarded as being at high risk for surgical complications due to obesity and related illnesses. We report two cases of patients with lesions severely limiting walking. The two patients weighed 490 and 520 lb, respectively. One patient had hypertension and asthma; the other had arrhythmias and chronic venous thrombosis. One patient had wedge resection of the right groin (23 lb) and knee (5 lb), and the second patient had resection of the right thigh (65 lb) and left thigh (84 lb). All procedures were done separately. Both patients reported improvement in walking. Simple wedge excision was an effective, minimally complicated treatment for these patients.

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Resection of lymphedematous tissue has evolved over the last century. Earlier approaches are epitomized by the so-called Charles procedure, which was originally applied to scrotal elephantiasis, but has now come to be defined as a procedure of the lower extremity. (1) This operation consists of resecting all skin and subcutaneous tissue in the affected part, harvesting the skin as split-thickness grafts from the surgical specimen, and applying these grafts to the fascia underlying the level of resection. Although functional results can be achieved with this approach, disfigurement and complications have been a prominent deterrent to consistent use of this operation. (1,2)

Homans (3) introduced the concept of preserving the skin overlying the lymphedematous subcutaneous tissue as flaps and using these skin flaps to cover the sites of resection. Fonkalsrud and Coulson (4) and Feins et a1 (5) developed this concept for treatment of lymphedema in children. Miller et a1 (6) labeled this procedure "staged skin and subcutaneous excision for lymphedema" and reported good long-term results in adult patients. (1,6) In their operation, lymphedematous legs are reduced in stages, starting with a medial resection. After healing, the lateral aspects of the limb are reduced, and further procedures are done as necessary.

The procedures using subcutaneous resection of skin flap coverage offer a real advance in control of leg swelling and preservation of full-thickness skin flap coverage with acceptable appearance. The procedures, however, are extensive and require multiple operations, all of which are followed by prolonged periods of bed rest. Adult patients with significant medical complications may be reluctant to undertake such an involved surgical course with total extremity recontouring as an endpoint, and their surgeons may share this reluctance.

We have recently treated patients with lymphedema and/or lipodystrophy, who have had significant medical problems and localized complaints related to specific areas of their disordered tissue. In such cases, segmental resection of tissue related to the patient's complaints was undertaken with functional improvement as a goal. We present two patients who illustrate this approach. Patient data and medical complications are outlined in Table 1. Details of the surgeries are summarized in Table 2.

Discussion

These cases raise a number of points in terms of diagnosis and management. First, what are these lesions? In the title, we refer to these lesions as "lymphodystrophic tissue" as a euphemism for the inability to explain these masses. Are they lipomas or other soft tissue lesions that have developed secondary lymphatic stasis over time? (7) Are they persistent lymphatic anomalies complicated by weight gain? (8) The lifelong history of these lesions and their exacerbation with age and obesity make both theories possible. Findings at surgery, including fibrous subcutaneous tissue and copious serous drainage, are grossly identical with findings in lymphedema, and microscopic characteristics are also generally similar to those of lymphedema. Therefore, whatever the original nature of these masses, they appear to come to a chronic lymphedematous stage. Weight loss or other nonoperative therapy appears to have no role in these problems.

Technically, the lesions in these patients were not subject to tourniquet control, an element used in most staged extremity resection. (1,4-6) Relatively bloodless resections were achieved in these cases by incising the most accessible base of the lesions and proceeding to excision by dissecting down to the posterior base. No elevating maneuvers were used. Neither patient required blood transfusion. The strategic approach used for these patients avoided any consideration of contouring any entire extremity or body region. By resecting defined, symptomatic masses, these operations were technically simple, bloodless, and without significant complications. Furthermore, the patients had no morbidity relative to their considerable medical problems.

Both patients reported substantial improvement in walking after these operations. Despite the intimidating array of physical, surgical, and medical problems found in these patients, these limited resections have proved to be beneficial and to have negligible morbidity.

Table 1

Patient Data

                          Patient 1                  Patient 2

Age (yr)                     38                         43
Height                    5 ft 9 in                  5 ft 3 in
Weight                     520 lb                     490 lb
Medical         First degree atrioventricular  Hypertention; asthma;
 complications   block; chronic deep venous     chronic bronchitis
                 thrombosis

Table 2

Operative summaries

                                    EBL
                                 Estimated   Specimen
Patient    Date    Procedure     blood loss   weight

1        08/30/00  Lipectomy,      100 ml     84 lb
                    left thigh
         02/07/01  Lipectomy,      100 ml     65 lb
                    right thigh
2        10/11/00  Lipectomy,      50 ml      23 lb
                    left groin
         04/11/01  Lipectomy,      50 ml       5 lb
                    right knee

Accepted December 17, 2001.

References

(1.) Heffel D, Miller T. Lymphedema of the extremity, in Achauer BM, Eriksson E, Vander Kolk C, Coleman JJ, Russell RC, Guyuron B (eds): Plastic Surgery: Indications, Operations, and Outcomes. St. Louis, C.V. Mosby Co., 2000, vol 1, pp 463-473.

(2.) Grace GT, Goldberg N. The modified Charles procedure for lymphedema praecox. Contemp Orthop 1993;26:l21,

(3.) Homans J. The treatment of elephantiasis of the leg. N Engl J Med 1936;215:1099.

(4.) Fonkalsrud E, Coulson WF. Management of congenital lymphedema in children. Ann Surg 1973;l77:280-285.

(5.) Feins NR, Rubin R, Crais T, O'Connor JF. Surgical management of thirty-nine children with lymphedema. J Pediatr Surg 1977;12:471-476.

(6.) Miller T, Wyatt LE, Rudkin G. Staged skin and subcutaneous excision for lymphedema. Plast Reconsir Surg 1998;102:1486-1501.

(7.) Mulliken J. Cutaneous vascular anomalies, in McCarthy JG, May JW, Littler JW (eds): Plastic Surgery. Philadelphia, W.B. Saunders Co., 1990, vol 4, ed 3, pp 3241-3250.

(8.) Clodius L. Lymphedema, in McCarthy JG, May JW, Littler JW (eds): Plastic Surgery. Philadelphia, W.B. Saunders Co., 1990, vol 6, ed 3, pp 4093-4120.

RELATED ARTICLE: Key Points

* Lymphodystrophic tissue can progress to disabling dimensions in lower extremities.

* This condition can coexist with complicated medical problems.

* Limited resection can be surgically done with manageable complications and functional improvement.

Case Reports

Patient 1

A 38-year-old man who weighed 520 lb presented with an adult history of obesity and a lifelong history of subcutaneous masses in the lower extremities. The patient could walk only using a walker and with difficulty. Examination showed large, pedunculated masses on the medial aspects of both thighs. These masses were chronically excoriated and mechanically disrupted his gait. The patient also had chronic cardiac arrhythmias and was receiving anticoagulant therapy for chronic deep venous thrombosis. With peri-operative support from cardiology and internal medicine, the patient had two procedures, 6 months apart, to resect both masses, which weighed 84 lb and 65 lb, respectively. Both procedures were done with the patient heparinized. With careful exposure, blood loss was negligible. Pathologic description of the specimens was "fibrolipoangiolipomatous hamartoma" of skin and soft tissue (Fig. 1). The specimens were composed of skin and fibrous connective tissue, with lesser amounts of highly vascularized fat. Th e dermis was markedly thickened (up to 5 cm), overlying alternating areas of fibrous connective tissue and fat. Figure 2 shows the patient standing without assistance after surgery.

Patient 2

A 43-year-old woman, whose weight was 490 lb at the initial visit, reported a lifelong history of irregular masses of skin and subcutaneous tissue. With age and weight gain, these areas had enlarged and become dependent. She complained of masses m the left groin and on the medial aspect of the right knee and described these lesions as interfering with walking. On examination of the left groin, the patient was found to have a large pedunculated mass originating from the left lower abdominal quadrant and lying on the patient's pubis and left thigh. Some chronic skin changes were present. A similar mass originating from the medial aspect of the right thigh was also found superior to the right knee. In addition, the patient had significant hypertension and asthma complicated by chronic bronchitis.

With careful medical management, the patient was brought to surgery for excision of the left groin mass, which weighed 23 lb. Recovery was uncomplicated. Six months later, the right knee mass of 5 lb was resected without complications. Blood loss for each procedure was less than 50 ml. Both lesions were described pathologically as consisting of skin and subcutaneous tissue. The left groin mass revealed prominent dermal fibrosis, focal suppuration, and multinucleated giant cell reaction (Fig. 3) as well as extensive perivascular lymphatic inflammation in the dermis and subcutaneous tissue (Fig. 4). The right knee mass showed dermal fibrosis with chronic focal inflammation. Eight months after the second operation, the surgical sites were well healed. The patient reported substantial relief from local symptoms and improvement in walking.

From the Division of Plastic Surgery, University of Mississippi Medical Center, Jackson, MS.

Reprint requests to William Lineaweaver, MD, Division of Plastic Surgery, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216. Email: [e-mail]

Copyright [C] 2003 by The Southern Medical Association

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