Surgical Options for Lower Leg Elephantiasis
For chronic lower leg elephantiasis, excisional debulking surgery using the Charles procedure or modified Charles technique is the definitive surgical treatment, achieving immediate volume reduction and excellent functional outcomes in 88-100% of cases. 1, 2, 3
Primary Surgical Approach: Excisional Debulking
The Charles operation remains the gold standard for advanced elephantiasis, involving complete excision of diseased subcutaneous tissue and skin down to the muscular fascia, followed by coverage with either:
- Split-thickness skin grafts (traditional Charles procedure) - reserved for tropical elephantiasis or severely damaged skin 1
- Vascularized skin flaps (modified technique) - preferred when local skin quality permits, providing superior cosmetic and functional results 1, 2
Expected Outcomes with Charles Procedure:
- Immediate volume and circumference reduction in 100% of cases 3
- Skin graft take rate of 88% 3
- Zero mortality in reported series 1, 2
- Mean healing time of 82 days with two-stage repair 2
- Hospital stay of 21-36 days 3
Alternative Surgical Options Based on Disease Stage
For Early-Stage Lymphedema (Before Elephantiasis):
Lymph nodovenous shunt (LNVS) should be performed before progression to elephantiasis, as it provides:
- Rapid relief in 62% of patients with early lymphedema 3
- Shorter hospital stay (7-10 days) compared to excisional surgery 3
- Avoidance of extensive tissue removal when disease is caught early 3
Critical caveat: LNVS becomes insufficient once elephantiasis develops, necessitating excisional surgery 3
Adjunctive Microsurgical Procedures:
For select cases, vascularized lymph node transfer can be combined with debulking surgery to restore lymphatic circulation 4. This approach is particularly relevant when:
- Patient has not responded to conservative treatment 4
- Goal is to restore some lymphatic function alongside volume reduction 4
Surgical Technique Modifications
The modified Auchincloss-Kim technique represents a contemporary refinement for elephantiasis nostras (non-filarial elephantiasis), involving:
- Tumescent microcannular laser-assisted liposuction as first stage 5
- Staged debulking with preservation of viable tissue 5
- Two-stage repair with mean interval of 34 days between procedures 2
Critical Postoperative Considerations
Common Complications to Anticipate:
- Delayed ulceration with lymphorrhea may develop after initial healing 5
- Infection is the most notable complication in excisional procedures 3
- Minor complications only when proper technique is employed 1
Management of Delayed Wound Complications:
If delayed ulceration occurs, treat with surgical necrectomy followed by vacuum-assisted closure (VAC therapy), which achieves complete healing 5. This complication does not negate the overall success of the procedure 5.
Contraindications to Conservative Management
Excisional surgery becomes necessary when:
- Lymphedema has progressed to elephantiasis stage 3
- Massive ectatic lymphatic vessels are present (podoplanin-negative on histology) 5
- Decongestive lymphatic therapy has failed 5
- Recurrent erysipelas occurs despite conservative treatment 5
Essential Pitfall to Avoid
Never delay excisional surgery in established elephantiasis hoping for response to conservative therapy alone - the histologic changes (massive ectatic podoplanin-negative lymphatic vessels) explain why decongestive therapy becomes ineffective at this stage 5. Early surgical intervention prevents 17+ years of disability as seen in case reports 4.
Postoperative Rehabilitation
Comprehensive physiotherapy intervention must begin immediately after surgical clearance to:
- Normalize functional capacity 4
- Restore strength and mobility 4
- Enable activities of daily living 4
- Maintain long-term volume reduction 1
Long-term compression therapy is mandatory following any surgical procedure to prevent recurrence 2.