Background: Lymphedema has been studied for many years now. It continues to intrigue many interested in this subject. Although much of the pathogenesis of lymphedema has been elucidated, treatment of this physically limiting disease is still in its early stages of evolution. Several methods of treatment have been advocated including complete excision of all suprafacial structures and skin grafting, staged excisions of subcutaneous tissue, microvascular lymph node transfer as well as aggressive liposuctioning of affected areas. All of these methods have improved the quality of life of patients treated when patient selection is strict, execution of the surgery is precise and post operative care including compression therapy is followed. The tradeoff with complete excision of lymphedematous tissue, which has very little recurrence, is a disfigured leg. With less radical excisions such as moderate liposuction or subcutaneous excision, recurrence is frequent. More radical subcutaneous excisions can result in significant skin loss.

Materials and Methods: Between August 2001 and April 2002 nine patients underwent surgical treatment of lymphedema using the technique of RRPP. Skin perforators were preserved in all cases and a radical excision of the subcutaneous perforators was performed. Microscopic dissection of the perforators was the technique used when direct radical excision was performed. 6 patients underwent treatment of lower leg lymphedema, 1 patient for the treatment of thigh lymphedema and 2 patients were treated for arm edema using this method. Preoperative Doppler was used to locate perforators in all patients.

Results: All patients had a significant improvement in the size of the involved extremity as measured by non-biased personnel. No recurrence of lymphedema was noted in the current follow up period. All patients had a significant improvement in life quality. Complications included superficial slough of skin in 2 patients, small full thickness defects in 2 requiring skin grafts. One patient with skin slough had a hematoma under the medial skin flap. Average number of perforators per patient was 2.4 per skin flap, range 2 to 5.

Conclusions: Treatment of moderate to severe lymphedema requires aggressive excision of scarred and involved tissue. Better understanding of the microvascular anatomy of the lower extremity with preservation of cutaneous blood supply along with the availability of Doppler ultrasonography can allow for a more radical excision of lyphedematous tissue while yielding a more aesthetically pleasing result with a low rate of complications. This new methods which has yielded promising results has great potential as a treatment method for lymphedema that can combine a curative excision with an aesthetically acceptable result.