A Comparison of Vascularized Cervical Lymph Node Transfer with and without Modified Charles’ Procedure for the Treatment of Lower Limb Lymphedema

Sir: We read with interest the article by Althubaiti et al.1 in a recent issue of the Journal. We agree that the use of physiologic methods of surgical management of lymphedema, such as vascularized lymph node transfer2 and lymphaticovenular anastomosis,3 are gaining popularity and are the way forward. Unfortunately, the intermediate- and long-term results of such procedures are still lacking at this time. Based on the senior author’s yet unpublished data, the reduction of lymphedema in advanced cases where only vascularized lymph node transfer is performed is usually incomplete, and requires additional excisional procedures for significant symptomatic relief. We present a case of bilateral lower limb lymphedema of 20 years’ duration occurring in a 51-year-old woman who was injured in a road traffic accident 30 years previously and was treated conservatively for contusion. Her preoperative circumferential measurements were 55.0, 44.0, 37.0, and 26.0 cm at the right midthigh, midleg, ankle, and midfoot, respectively; and 50.0, 42.0, 32.0, and 24.0 on the left side, respectively (Fig. 1, left). Lymphoscintigraphy showed bilateral lower limb tracer uptake delay (Fig. 2). She initially underwent free vascularized lymph node transfer to the right ankle from the transverse cervical lymph node chain. One year after the first operation, her circumference measurements were 52.0, 42.0, 36.0, and 26.0 cm for the right side and 49.0, 41.0, 31.0, and 24.0 cm for the left side (Fig. 1, second from left). Because the patient desired further improvement than what was attained on the right side, she agreed to proceed with vascularized lymph node transfer from the left supraclavicular region to the left ankle and a modified Charles procedure concurrently to the left lower limb. She was followed up at 2 years after vascularized lymph node transfer on the right lower limb (also 1 year after vascularized lymph node transfer with the modified Charles procedure on the left lower limb). Her limb circumference measurements were 46.8, 42.8, 26.2, and 24.2 cm for the right and 35.2, 32.1, 21.0, and 25.6 cm for the left (Fig. 1, second from right and right). Because of superior symptomatic relief of the left lower limb compared with the right, she prefers the result on the left over that on the right despite the more extensive scar, and is awaiting a modified Charles procedure to the right lower limb (in addition to the previous lymph node transfer).Fig. 1: (Left) Preoperative photograph of the patient. (Second from left) Photograph of the patient 1 year after vascularized lymph node transfer to the right ankle. (Second from right and right) Photographs of the patient 2 years after vascularized lymph node transfer to the right ankle and 1 year after vascularized lymph node transfer and a modified Charles procedure to the left lower limb.Fig. 2: The first two images (left and second from left) were taken 30 minutes after injection of contrast, and the next two (second from right and right) were taken at 2 hours after injection, and demonstrate delayed uptake of contrast.This is a unique case in which a patient gave consent for different procedures on each lower limb, and allows us to make a direct comparison of the postoperative result of the respective procedures, because the patient serves as her own control. Based on the result obtained from vascularized lymph node transfer alone,4 the authors recommend that excision surgery, such as a modified Charles procedure, should be performed concurrently for optimal results in advanced cases of lymphedema. This is based on our experience of 30 cases of combined vascularized lymph node transfer and modified Charles procedure, which shows promising result for advanced lymphedema, and will be presented in a separate article in the near future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Matthew Sze-Wei Yeo, F.A.M.S.(Plast.), M.R.C.S.Ed. Seong Yoon Lim, M.D. Kidakorn Kiranantawat, M.D. Pedro Ciudad, M.D. Hung-Chi Chen, M.D., Ph.D.