Radical excision of lymphedematous tissue with skin grafting (Charles
operation) may be required for patients with advanced fibrosclerotic l
ower extremity lymphedema. Complications of this procedure include pap
illomatosis, wart formation, intractable skin ulcerations and weeping
of lymph and are often considered major drawbacks of the operation. We
have largely circumvented these sequelae by burying a strip of shaved
split-thickness skin graft into the deep subcutaneous tissue thereby
modifying the Charles operation. The strip of deepithelialized skin se
emingly connects the superficial dermal lymphatics with subfascial dee
p lymphatics thereby facilitating lymph drainage and minimizing lymphe
dema accumulation and the complications outlined above. We have now tr
eated 4 patients with advanced primary fibrosclerotic lymphedema using
this modified technique. Not only were the patients improved in appea
rance and function with less trophic changes, but lymphscintigraphy us
ing 99mTc-dextran also suggested improved interstitial tracer transpor
t.