THE SURGICAL CORRECTION OF CHRONIC LYMPH(EDEMA OF THE LEGS

By THOMAS GIBSON, M.B., F.R.C.S.(Ed.), and J. SCOTT TOUGH, M.B., F.R.C.S.(Ed.)

From the Plastic Surgery Unit, Royal Infirmary, Glasgow

ELEPHANTIASIS, or chronic lymphcedema of the legs, is an uncommon but by no means rare condition in temperate countries where filariasis is unknown. It starts as a pitting cedema of the dorsum of foot and ankle which slowly spreads to involve the lower leg and later the thigh, and unless kept in check it is slowly progressive so that the affected leg may reach an enormous size. At first the swelling subsides completely with recumbency and elevation of the leg and may be controlled by firm pressure bandaging ; later the progressive fibrous organisation of the cedematous tissue which ensues prevents a complete return to normal size even with prolonged rest, and it is in such cases that surgical correction is indicated. During the last ten years we have operated on twenty-six cedematous legs of this type and the main concern of this communication is with the operative technique evolved. For this reason only the salient points of a~tiology and pathology in so far as they affect treatment and the present series of cases are discussed. For more detailed reviews the reader is referred to the works of Allen (I934), Drinker and his colleagues (I934,1935, and I94I), Boyd (I95O), Aird (I95O), Kinmonth (I952), and Watson (I953).

-,~TIOLOGY AND PATHOLOGY

Drinker et al. (1934) showed in dogs that complete blocking of the lymphatics of a limb resulted in chronic lymphccdema, and while it seems probable that a similar blockage exists in human cases (Hornans, I936 ) the cause of this block is frequently unknown, hence the names idiopathic lymphccdema and elephantiasis nostras. There arc, of course, certain patients in whom an obvious cause exists as, for example, those in whom trauma, surgical removal of the lymph glands or lymphatics, or their invasion by malignant disease, is responsible for the lymphatic block. These, however, constitute only a small minority.

Infection producing an obliterative lymphangitis is a possible cause, but the exact role of infection is difficult to assess. Drinker et al. (I935) showed that dogs in whom lympho~dema had been produced by mechanical obstruction of the lymphatics were subject to recurrent attacks of infection in the affected limb. Similar bouts of infection in human cases may therefore bc secondary in nature and not the primary cause. The fact that such attacks have ceased in our patients after excision of the ~edematous tissue confirms this view. On the other hand, the effect of filariasis is well known, and the occasional case in which the swelling increases with each infective attack suggests that infection may sometimes play a part. Castellani (I952) believes that a specific organism, the Micrococcus metamyceticus, is responsible. He has isolated this organism from cases of the disease and claims that a vaccine effects temporary improvement. It must be

stressed, however, that attacks of infection are by no means an invariable accompaniment and were absent from the majority of our cases.

I95

196 B R I T I S H J O U R N A L OF PLASTIC SURGERY

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THE SURGICAL CORRECTION OF CHRONIC LYMPHfEDEMA OF THE LEGS 197

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198 B R I T I S H JOURNAL OF PLASTIC SURGERY

It is possible that a congenkal deficiency in the lymphatic drainage may be present. Milroy (1892 and 1928) reported a series of cases in one family in whom the condition was present at birth. Several other instances of an inherited trait have been published, but in these the condition was not commonly congenital, the onset most frequently occurring about puberty. In two of our patients the swelling was present at birth and in one of these there was a familial trait. The majority of the idiopathic lesions, however, appear about puberty, and Allen (1934) named this group "lymphoedema prmcox" since in 65 per cent. of ninety-three cases which he reviewed the onset occurred between the ages of IO and 24. The predominance of the disease in females--87 per cent. in Allen's series--is unexplained.

Although the majority of cases referred for plastic surgical treatment are probably due to abnormalities of lymphatic drainage, Boyd (195o) frequently noted smooth valveless veins while investigating a series of sixty-nine cases of lymph~edema of the legs with phlebograms. This suggests that deep venous stasis may be an early factor. Three of our patients had a history of previous whke leg.

One important influence is undoubtedly the effect of gravity, since if this is nullified by confining the patient to bed and elevating the leg a considerable lessening of the ~edema resuks in a few days and in the early case a return to normal size may result. This may be due to one or more reasons : the lymphatic block may not be absolute, the blood-vessels themselves may be able to absorb slowly the ¢edema fluid or the fluid may drift proximally along tissue planes and be absorbed through normal lymphatic channels. The ease with which the excess fluid is removed, when freed from the increase in hydrostatic pressure imposed by gravity, also supports the theory that incompetence of the lymphatic valves may be an mtiological factor in these cases.

The ~edema is entirely confined between the skin and the deep fascia of the leg and its persistence leads to a gradual overgrowth of fibrous tissue in this subcutaneous compartment. This fibrosis can be demonstrated at operation as being most marked just superficial to the deep fascia, which itself may be greatly thickened. In the established cases it is this fibrous replacement which prevents a return to normal with rest and elevation and dooms to failure operations designed to " d r a i n " the limb. In these, surgical correction is necessary. Although a late stage of the disease is described in which fibrous replacement is complete and a non-pitting oedema results, all our patients have shown some pitting on pressure while ambulant. After some days of rest and elevation, however, when the excess fluid had been absorbed the residual swelling was non-pitting.

The skin may remain healthy for many years--a point of some importance in treatment--but in the gross long-standing case it may become ulcerated and extensive areas of scarring or pigmentation result.

The present series of cases consists of twenty patients, the details of whom are given in Table I. Since the duration of the condition varied from two to twenty-six years it was not always possible to obtain an accurate history of the origin of the complaint, and the summary of the a~tiological factors given in Table II must be regarded as approximate only.

In the post-traumatic cases the condition is, of course, confined to the injured leg ; in the idiopathic group it may be unilateral or bilateral, and if bilateral the legs may be affected in varying degree. The genitalia may also be involved, but only one of the patients (Case 4) showed this feature.

THE SURGICAL CORRECTION OF CHRONIC LYMPHO~DEMA OF THE LEGS

TABLE II

Summary of 2Etiological Factors in the Present Series

Pos t - t r auma t i c

I d i o p a t h i c - (a) Congeni ta l . . . (b) Congeni ta l and Hered i t a ry (e) W i t h o u t infective attacks (d) W i t h infective attacks . (e) W i t h a poss ib le venous factor .

Total. Bilateral. 4 o

i I

i I

6

5 I

3 I

I99

SURGICAL T R E A T M E N T

Historieal .--The logical therapeutic approach to any pathological condition is the removal of the cause and many attempts have been made to overcome the postulated lymphatic block in chronic lymphcedema. The implantation of silk threads across the barrier by Handley (I9O8), the excision of long strips of the deep fascia by Kondol~on (I912), and the implantation of fresh lymphatic bearing tissue in the form of skin flaps and tubed pedicles (Gillies and Fraser, I935 ; Mowlem, I948) are the most important of these. In general these operations have given only temporary relief, much of which could be accounted for by the enforced rest in bed. One outstanding exception is the case reported by Gillies and Fraser (I935) and later followed up by Gillies (I95 o) in which permanent relief appears to have been achieved.

Leaving aside the highly debatable point of whether or not such operations do provide fresh lymphatic channels, they must fail to correct the condition in the long-established case because of the fibrous organisation of the oedematous tissue. In such cases radical excision of the diseased tissue offers the only hope of relief.

It is interesting to note how the concept of radical excision gradually evolved from the Kondol6on procedure. This operation was based on the observation that the ~edema is confined to the subcutaneous compartment and the deduction that the deep lymphatics of the muscle compartments were unaffected and drained normally. It is extremely doubtful if this is the case and experience of the operation showed that little or no drainage did occur. Nevertheless, as modified by Sistrunk (I918 and I927) to include an excision of broad ellipses of skin and oedematous tissue it was a useful procedure. Sistrunk realised the importance of removing the largest possible amount of diseased tissue and by so doing achieved a con- siderable improvement in the size of the leg. Unless firm support was maintained, however, the condition recurred (Ghormley and Overton, I935). Pratt and Wright (I94I) went further and excised three-quarters of the oedematous tissue by extensive undermining of the skin flaps; abdominal pedicle flaps were used to make good any skin loss. Again, however, adequate post-operative support was essential.

Homans (i936) was the first to describe an operative procedure designed for the complete ablation of the diseased tissue on the lower leg, a multiple staged excision in which access was obtained by raising a series of longitudinal skin flaps which were replaced to cover the defects. Since then several other techniques

200 B R I T I S H J O U R N A L OF P L A S T I C SURGERY

have been described, some single staged, some multiple, all aimed at more or less complete excision of the oedematous tissue but differing from Homan's method in the use of free skin grafts to repair the defect (Macey, 194o and 1948 ; Poth et al., 1947 ; Mowlem, 1948 ; Blocker, 1949 ; Farino, 1951 ; Campbell et al., 1951 ; Pratt, 1951 and 1953). The more important features of these techniques are discussed below.

Present Series.raThe first four cases in our own series were treated by a modification of the Homans' technique. A longitudinal flap of skin based on the midline posteriorly was raised from about half the circumference of the leg, the underlying o~dematous tissue excised, and the flap replaced. The skin was dissected off just deep to the corium and the flap survived partly as a pedicled graft, but mainly as a free full-thickness graft ; the other half of the leg, the dorsum of the foot, and the areas around the malleoli were dealt with at separate operations. Watson (1953) has developed this method so that the lower leg and foot may be dealt with in two stages.

The method proved to be laborious and tedious for both patient and surgeon. Since ~edema would tend to recur in any subcutaneous tissue left adhering to the skin flap, painstaking care must be devoted to the dissection of this flap and this is the most time-consuming part of the operation. The technique has therefore been gradually modified in succeeding cases with the ultimate aim of dealing expeditiously with the whole of the lower leg and foot in one operation. Some of our modifications are paralleled by those of other workers ; some are new.

Free Skin Grafting after Excision.--The careful scalpel dissection of the skin flap in the Homans' procedure is so tedious, and so little advantage accrues from its pedicle attachment that the first obvious improvement, as other writers have realised, is the use of a completely free graft after excision. Although some workers have used split-skin grafts from thigh or abdomen (Macey, Mowlem, Campbell et al.), the skin covering the oedematous lower leg, when healthy, is the natural source of supply. Poth et al. (1947) and Farino (1951) cut split-skin grafts from this skin before excising the mass. Pratt (1953) uses the electric dermatome for this purpose and is enthusiastic about its value in cutting grafts around the creases of the most grossly cedematous leg. The chief disadvantage of obtaining the free grafts in this way before excision is that only relatively narrow strips can be cut even with the electric dermatome.

We have found it simpler and more expeditious to cut the graft from the oedematous mass after its excision. Provided that care is taken to obtain a flat surface, grafts of any length and with a maximum width of 5 to 6 in. may be obta~,ned with a Humby knife, and three such grafts will easily cover the whole of the lower leg and dorsum of the foot. Blocker (1949) also cuts the grafts from the excised mass using a dermatome, but the maximum size of such grafts-- 8 by 4 in.--is too small for the purpose.

Access to the Whole Leg.--Our first cases carried out by the free grafting technique (1947 to 195o) had a series of excisions of strips of skin and oedematous tissue about 5 in. wide, the skin being replaced in one sheet as a free graft. This, however much simpler from the surgeon's point of view, required as many operations as the Homans' procedure. The difficulty of decreasing the number of stages lay mainly in the problem of easy access to the whole leg, and this was first solved by raising the leg to a vertical position by means of a plaster of Paris

THE SURGICAL CORRECTION OF CHRONIC LYMPH(EDEMA OF THE LEGS 201

shoe to which was attached a rope passing over a pulley in the roof. This allowed access to the whole circumference of the lower leg but covered the dorsum of the foot. Bone traction from the calcaneus was then tried, at first by means of a Kirschner wire, later by the simpler and safer ice-tong calliper, and this was found to give excellent access to both the lower leg and foot. Vertical suspension has the added advantage of decreasing haemorrhage and simplifying haemostasis.

The :Extent of the Excision.--Like most other workers we have confined the excision to the lower leg and the dorsum of the foot, and in only one instance have we removed any tissue from the thigh and that merely to correct an unsightly bulge (Case 8). There is, however, considerable variation in the extent of the excision in the published techniques. Poth et al. (I947) spared an anterior strip over the tibia and an area over the heel and tendo Achillis ; Blocker (I949) included the strip over the tibia but still spared the heel and tendo Achillis ; Pratt (I95I) did not deal with the dorsum of the foot at all because of the danger to tendons, but now he includes this in the dissection (Pratt, r953). Farino (I95I) excised all the subcutaneous tissue below the knee with the exception of the sole of the foot and toes.

At first we excluded strips over the tibia and the tendo Achillis, but later found it safe to remove these. We still, however, spare an area which covers both malleoli and the calcaneus because of the possible sequelae of failure of a free graft in these sites. These areas are, however, " t h i n n e d " as far as possible at the original dissection.

The Use of a Tourniquet.--Pratt (I953) states that " a tourniquet cannot be applied successfully to these limbs " and finds it not unusual to transfuse 4,0o0 to 5,0oo ml. of blood during the operation. This has not been our experience although there are certain difficulties to be surmounted. When pressure is applied to the thigh there is a dispersal of (edema fluid and the pressure diminishes. Non-adjustable tourniquets of the Esmarch's bandage type are, therefore, not very suitable, since they give only a short period of complete vascular occlusion followed by arterial leak and congestion of the leg. The cloth cover of the standard pneumatic cuff supplied for sphygmomanometer readings on the thigh is too short to encompass adequately the lymphoedematous thigh and slips badly when inflated. We therefore had a special cover made, 8o in. in length, which will wrap three or four times around the thigh. This, when bound in place with a crepe bandage and fixed above and below with elastoplast, makes an efficient tourniquet requiring only occasional repumping.

Present Surgical Technique . - -The technique to be described is that which has been finally evolved. It enables the whole lower leg and foot to be dealt with in one stage, the operating time is under two hours, blood loss is minimal, and post-operative shock has not occurred. Good teamwork is necessary, and two surgeons work together with one or two assistants.

Bone traction is first applied to the calcaneus of the affected leg by means of an ice-tong calliper. A rope is attached which passes over a pulley in the theatre roof and the leg is raised to a vertical position (Figs. I and 2). The end of the operating table is then dropped so that the other leg hangs downwards from the knee. A pneumatic tourniquet is placed around the upper thigh as described above and the pressure maintained at 2oo ram. Hg.

The incisions used are shown in Fig. 3. The midline posterior incision is

FIG. I

F I G . 2

Fig. I . - - T o obta in access to the full c i rcumference of the lower leg and to the d o r s u m of the foot, the affected leg is su spended by m e a n s o f an ice- tong calliper inser ted in the calcaneus and a rope pass ing t h r o u g h a pul ley in the theat re ceiling ; the o ther leg hangs down- wards f rom the knee. A p n e u m a t i c tou rn ique t is appl ied to the thigh.

Fig. 2 . - - A plaster o f Paris shoe provides an alternative m e t h o d of suspens ion w h e n bone t ract ion is contraindicated, as for example w h e n the skin is ulcerated. T h e area on the do r sum of the foot m u s t of course be dealt wi th at a secondary operation.

Fig. 3.---A d iagrammat ic representa- t ion o f the incisions used and the skin replacement . A and 13 show the extent o f the

excision. C il lustrates the " t h i n n i n g " o f the

area below the knee by excising a wedge- shaped mass of subcu- t aneous t issue. T h e areas over the malleoli are similarly treated.

D and E show the free grafts su tu red in position. FIG. 3

A B

D E

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Y

THE SURGICAL CORRECTION OF CHRONIC LYMPH(EDEMA OF THE LEGS 203

deepened down to the fascia over the gastrocnemius and the dissection proceeds forwards, one surgeon on each side. We have retained the deep fascia unless a previous Kondol~on operation has been performed or the fascia has been greatly thickened. In dissecting deep to the deep fascia care must be taken not to stray along the intermuscular septa or open the tendon compartments on the front of the ankle.

The mass of skin and subcutaneous tissue having been excised, one surgeon completes the dissection by removing any tags of subcutaneous tissue adhering to the deep fascia and by undermining and thinning the area just below the knee and the triangular flaps over the malleoli. The tourniquet is then released and h~emostasis secured.

Meanwhile the other surgeon prepares the skin graft from the excised mass. This is first cut into three labelled strips as shown (Fig. 4), each of which is

FrG. 4 After excision the mass o f skin and oedematous t issue is divided

into three labelled strips.

flattened out on a board by judicious packing with cotton-wool. A few longitudinal incisions through the oedematous subcutaneous tissue correct any tendency to curl at the margins.

An assistant then steadies the corners with tissue forceps and the graft is removed from the surface with the Humby knife in the usual way (Fig. 5). The graft is cut at just less than full skin thickness, and provided that sufficient care has been taken to obtain a flat surface all the skin may be removed with ease apart from some very slight loss at the end of each strip. The three strips of skin are sutured together in their original sequence (Fig. 6). By this time ha:mostasis on the leg has been secured, the undercut areas below the knee and over the malleoli have been thinned, and the skin edges at these points tacked down to the raw surface with catgut sutures. The graft is then applied and stitched in position to the skin edges. There is always an excess of skin circumferentially and this is excised posteriorly in such a way that the posterior suture line lies centrally.

204 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 5 Each strip is placed on a wooden board and an even surface obtained by cotton-wool padding. The skin is removed with a H u m b y knife at practically

full-thickness level.

FIG. 6

The three strips of skin are sutured together with a running mattress stitch in their original position before reapplying them to the leg.

THE SURGICAL CORRECTION OF CHRONIC LYMPHCEDEMA OF THE LEGS 205

A firm pressure dressing consisting of well-packed flavine wool and crepe bandages is applied and the leg splinted by a posterior plaster slab. The foot of the bed is raised and the dressings are not touched for ten days. Vascularisation of the very thick grafts used is slow and two or three weeks elapse before it is complete.

Post-operative Course.--With one exception in which a 2o per cent. loss occurred from ha:matoma formation, a 95 to IOO per cent. " t a k e " of the free grafts has occurred and only occasionally has there been sufficient loss to warrant a few secondary stamp grafts. The patient is allowed up only when healing is complete and then only with firm pressure bandaging on the lower leg and foot. It is important, we feel, that for several months after operation this pressure be maintained at all times when the leg is dependent to avoid any chance of breakdown along the suture lines. Stiffness of the ankles is common on the first attempts at walking, but this seldom persists more than a few days.

RESULTS

For the purposes of this report all the patients in the series were reviewed in October I953. One had died of intercurrent disease and two could not be traced ; the remainder were seen and examined. In discussing the results the traumatic cases are dealt with separately, since they form a special group in which factors other than the lymphoedema may affect the prognosis. The results of treatment in the idiopathic cases are discussed in relation to the operative procedure used.

Traumat ic Lymphcedema . - -One patient (Case 5), who had been treated by multiple excisions and free grafting, died of essential hypertension about one year after operation ; the immediate result had been good. The remaining three patients (Cases 8, 9, and I4) had a one-stage circumferential excision carried out. Case 8 (Figs. 7 and 8) has had no trouble with the leg, although there is a slight tendency for the (edema above the knee to increase. There is also a slight irregular 0edema of the dorsum of the foot, which pits slightly on pressure. This has been a not uncommon finding and is due to the difficulty of removing all the affected tissue in this site without denuding the tendons.

Cases 9 and I4 are unsatisfactory. The lymphoedema in each instance had followed a severe injury with skin loss in the region of the knee. Case 9 developed an infected dermatitis of the leg following operation which progressed to ulceration. The infection subsided and the ulcers healed with prolonged rest in bed but recurred when she was ambulant. Eventually the patient herself requested amputation and this was carried out. Case I4, while much improved, has had repeated trouble with breakdown of small areas of the skin grafts, a complication with which we have not met in any other case in the series. It seems likely that in both these patients the original trauma had resulted in impairment of the blood supply of the limb, particularly of the venous drainage.

Idiopathic L y m p h ~ d e m a . - - ( i ) Homans' Method.--Of the three patients subjected to this procedure two cannot now be traced. They were followed up for at least a year after operation, however, and photographs taken at that time show the results to be fairly satisfactory in appearance. A certain amount of

206 BRITISH JOURNAL OF PLASTIC SURGERY

oedematous tissue persists along the midline posteriorly where the bases of the two flaps meet, and one patient (Case I) shows warty nodularities towards the base of the toes.

The remaining patient (Case 3) has had almost continuous trouble with the leg since operation in I947. In this case, shortly after becoming ambulant, thin cracks appeared in the skin of the lower leg through which serous fluid seeped and crusted. Later, infection supervened. This condition, which appears

FIG. 7 FIG. 8

Fig. 7.--Case 8. Female~ aged 39. Gross lymphcedema which followed an injury to the leg and operations to the knee and groin in early childhood.

Fig. 8.--Case 8. The appearance of the leg three years after operation. The relative thinness of the left leg is accentuated by a mild degree of oedema in the right.

clinically to be a physical leakage of lymph through the skin rather than of infective origin, has proved resistant to all the usual dermatological remedies, although temporary relief is obtained with prolonged rest in bed. The reason for this distressing complication has not been determined. It has not been seen in any other case.

(2) Multiple Excisions.--Two patients (Cases 4 and 6) were treated by this method. In both instances the results are poor cosmetically although the patients are satisfied with the improvement in appearance and function and the freedom from recurrence of the acute attacks of cellulitis which they had had before operation. It was difficult technically to be certain that all the subcutaneous tissue was excised at the junction between successive excisions, and small irregular oedematous masses are present along the suture lines. Case 4 has marked lymph- oedema of the toes, and chronic infection is present within the folds and extends on occasion upwards over the foot and ankle. He has also marked nodular wart-like excrescences around the ankle (Fig. I3).

THE SURGICAL CORRECTION OF CHRONIC LYMPH(EDEMA OF THE LEGS 207

(3) One-stage Circumferential Excisions.--The fourteen patients (eighteen legs) in this group have all been operated upon in the past two and a half years and the results to date have been very satisfactory (Figs. 9 t o I 2 ) . The skin grafts have remained stable and there has been no recurrence of the oedema with the exceptions noted below.

The cosmetic results are much better than those achieved by the other methods in our hands. These legs are, of course, thinner than normal ; this is not of great

FIG. 9 FIG. I0

Fig. 9 . - -Case 7. Female, aged 31. Moderate ly severe case of bilateral idiopathic lymphoedema. T h e scar following a previous Kondol4on operation can be seen on

the right leg. Fig. Io . - -Case 7- Post-operative photograph. T h e area just below the knee has been well " th inned " on the left side but inadequately on the right giving a slight

" p l u s fours " effect.

importance in the bilateral case but may be very obvious in the unilateral, particu- larly when mild lymphoedema is present in the other leg. The usual abrupt line of the excision just below the knee, tending towards a "plus-fours " appearance, is greatly lessened by the thinning of the skin flaps above the area of excision. In those cases in whom the dorsum of the foot was dealt with separately, the junction line at the ankle shows as a slightly oedematous ridge. This has been avoided in the later cases where the whole excision has been completed in one stage. Many of the patients, too, show occasional small cedematous areas on

FIG. I i FIG. i2

Fig. i i . - -Case 12. Female, aged 37. Mild case of unilateral idiopathic lymphcedema increasing very slowly

in size over ten years.

Fig. I2.--Case 12. The result one year after operation. A good cos- metic appearance can be expected in this type of case when the disease is entirely unilateral and the thigh

involved only to a minor degree.

Fig. I3.--Case 4. Male, aged 27. Severe bilateral lymph(edema of twelve years duration, treated by multiple excisions and skin replace- ment, a strip over the subcutaneous surface of the tibia being spared. The illustration shows the inner aspect of the left ankle and the nodular excrescences which have developed on the free graft four years after operation. Some appear to be due to persisting remnants of ~edematous tissue below the graft, others are probably dyskeratotic in origin. In a milder form similar changes have been noted in other cases at the ankle and at the base

of the toes.

FIG. x3

THE SURGICAL CORRECTION OF CHRONIC LYMPH(EDEMA OF THE LEGS 209

the dorsum of the foot which do not, however, incommode them in any way ; they are related to the difficulties of completely radical excision in this area.

With the passage of time the grafts have tended to develop a nodular or warty appearance in two sites--around the tendo Achillis and towards the base of the toes. Fig. 13 previously referred to is the most gross example of the condition which we have seen. The cause of this is obscure, but it may be due to persistence of small fragments of oedematous tissue in these sites. Some of them, however, are probably dyskeratotic in nature.

Case 13 has complained since operation of pain in the sole of the foot, and tenderness can be elicited on pressure over the heads of the third and fourth metatarsals. She also had complete anmsthesia of the lateral three toes and the lateral side of the foot, which recovered slowly. These symptoms do not accord with operative damage to any single nerve trunk and one must conclude that excessive pressure on the graft over the dorsum of the foot damaged the digital nerve supply to these toes. The metatarsalgia may have been precipitated by the same cause.

DISCUSSION

The one-stage operative technique described above has proved not only a much simpler and less formidable procedure, but gives a much better cosmetic and functional result than the methods previously used. For this reason we have tended recently to carry out the operation in milder cases where previously we might have hesitated to advise it, and some of the best cosmetic results have in fact been obtained in such cases.

However, the decision as to what degree of lymphcdema justifies operation must still be an individual one. Life may be intolerable to a young woman with a degree of swelling which would be of little moment in a man. Recurrent attacks of acute infection in the limb should always be an indication for operation, since our experience has been that such disabling attacks do not recur after excision of the ~edematous mass. The rate of progression of the lesion must also be taken into account. This varies considerably, and when the leg is steadily increasing in size operation is best carried out as early as possible.

In the case of lympho~dema of traumatic origin, operation should be advised with caution. Our experience, though small, suggests that the end result may be poor when the original lesion has resulted in vascular impairment of the lower limb in addition to the lymphatic blockage.

It is to be hoped that eventually a fuller understanding of the mtiology of lymph~dema will render obsolete operations of this kind. It must be remembered, however, that even should methods be devised to overcome or correct the lymphatic block, operation will still be required in the long-established case because of the irreversible fibrous organisation of the ~edematous tissue.

SUMMARY

I. The mtiology of lymph~edema of the legs and the methods of surgical correction are briefly discussed.

2. An operative technique is described which enables the whole of the lower leg and foot to be dealt with in one operation.

3 B

2 1 0 B R I T I S H J O U R N A L O F P L A S T I C S U R G E R Y

3. The operation can be completed within two hours, and blood loss and shock are minimal.

4. The results of various operative methods in a series of twenty patients with lymph0edema are discussed.

5. The results obtained by the one-stage excision and grafting technique. have been superior cosmetically and functionally to those obtained by other methods.

REFERENCES

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