Charles procedure for lymphedema: a warning.

Five patients with lower extremity lymphedema treated by subcutaneous excision and split-thickness graft resurfacing (from the opposite extremity) have been followed up. Three of these patients underwent amputation of the leg because of exophytic changes within the grafted skin, chronic cellulitis and skin breakdown. Resurfacing with a split-thickness graft causes a deformity that is significantly worse than the original lymphedema. In the Charles procedure (subcutaneous and deep fascial excision followed by full-thickness grafts), deep muscle fascia should be excised with the subcutaneous tissue and the extremity resurfaced with more durable full-thickness grafts taken from the excised tissue. However, the risks of graft failure should be considered. Over the past 9 years, 25 patients with lymphedema have been successfully managed by staged subcutaneous excision beneath flaps. This procedure safely provides consistent reduction in size, improvement in function and very satisfactory esthetic results. In the author's opinion the Charles procedure is therefore preferred for treating lymphedema of the extremity.