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Charles Procedure

Related Terms: Charles Procedure, Thompsons Procedure, Buck's Fascia, Homans-Miller Procedure, Kondoleon Procedure, Sisktrunk Procedure, Thompson Procedure, Lymphedema Microsurgery, Dermal Flap, Miller Sistrunk Procedure, Surgical Therapy, Elephantiasis. Lymphedema, Penoscrotal.

Introduction One particular surgery is still used to “treat” lymphedema is called the Charles Procedure.

The Charles procedure (1912) is an ablative procedure whereby the affected subcutaneous tissue is resected down to muscle fascia and the area covered with skin grafts taken from the resected specimen. This procedure is no longer performed. The Charles procedure, as an eponym for the surgical treatment of leg edema, is actually a longstanding misnomer, seeing as Sir Richard Henry Havelock Charles is known for describing a treatment for scrotal lymphedema in 1901, having treated a series of 140 patients with this condition. Sir Havelock had never treated a patient with leg edema, but in 1950, Sir Archibald McIndoe, an eminent British plastic surgeon wrote an article in which he mistakenly claimed that Sir Charles had treated a patient with leg edema with excision of subcutaneous tissue and skin grafts back in 1912. Since then, the error has been propagated throughout the years.

The gold standard that in this author's opinion that should be used for the treatment and management of lymphedema is manual lymphatic drainage (MLD), also referred to as complex decongestive therapy.

For extended information on surgeries, please review our page Surgery for Lymphedema.

The central problem involving surgeries is (1) they cause extensive nerve damage (2) the swelling will soon return (3) the surgery exposes the lymphedema patient to the possibility of severe or life threatening surgery and (4) there is often a serious need for further skin grafts. It is therefore absolutely inexcusable for any physician to recommend, suggest or perform the surgeries.


Dec. 24, 2011

I have long been an outspoken opponent on the use of debulking surgeries for lymphedema patients. In my article Complications of Debulking Surgery, I shared my own experience with this proceure and the long term effects on my left leg.

Abstracts and Studies

Treating chronic lower limb lymphedema with the charles procedure in a renal allograft recipient.

Jan 2012

Wu HS, Cheng HT, Chen HC.


From the Department of Surgery, Subdivision of Plastic and Reconstructive Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan.


We report our experience in applying the Charles procedure to a female renal allograft recipient for her left lower leg lymphedema. This is a rare comorbidity in limb lymphedema victims, and the use of the Charles procedure has not been reported in such an immunocompromised patient. After surgery, infection was well controlled, and there was minimal scar in the affected limb.


Optimizing outcome of Charles procedure for chronic lower extremity lymphoedema.

Apr 2011

Karri V, Yang MC, Lee IJ, Chen SH, Hong JP, Xu ES, Cruz-Vargas J, Chen HC.


Department of Plastic and Reconstructive Surgery, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan, Republic of China.


BACKGROUND: The Charles procedure for late-stage lower limb lymphoedema (LLL) is often criticized for its unpredictable and poor results. We have adopted a systematic approach to optimize outcome of patients treated with this excisional surgery.

METHODS: From June 2004 to March 2009 we performed the Charles procedure on 1 lower limb of 19 women and 8 men with late-stage LLL. Mean age and follow-up was 48 (range, 16.5-77.8) years and 21.6 (range, 1.5-48) months, respectively.

RESULTS: Average inpatient stay was 27 (range, 11-54) days. After discharge, 16 (59.3%) patients underwent further minor surgery. The most frequent complication was a single, short episode of cellulitis, affecting 5 (18.5%) patients. Self-reported mobility was either the same or improved at 6 months, and appearance of their limbs satisfactory.

CONCLUSIONS: The Charles procedure is an effective treatment for selected patients and by applying our systematic approach, a positive outcome can be achieved.

Annals of Plastic Surgery

Lippincott, Williams, Wilkins

Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment.

Jun 2009

van der Walt JC, Perks TJ, Zeeman BJ, Bruce-Chwatt AJ, Graewe FR.


Department of Plastic and Reconstructive Surgery, Tygerberg Hospital/ University of Stellenbosch, Francie van Zijl Drive, Parow, Private Bag X3, South Africa.


OBJECTIVE: The Charles procedure is an aggressive operation usually only indicated for severe lymphedema as it often yields an unpredictable outcome. We modified this procedure in order to achieve predictable results.

METHODS: The modification entailed the use of a negative-pressure dressing after the initial debulking surgery and then the delay of skin grafting by 5 to 7 days. Patients were graded by means of a lower limb functional scale to assess their functional status pre- and postoperatively.

RESULTS: Eight patients with severe primary lymphedema underwent a modified Charles procedure. All patients underwent this procedure without any major complications with an average resection of 8.5 kg of lymphedematous tissue. Minor complications included operative blood loss and additional regrafting (3 patients). The average follow-up was 27.3 months.

CONCLUSION: The results show a dramatic functional improvement in quality of life and a high overall satisfaction rate of patients undergoing this procedure. Our modification makes this a relatively simple procedure with a predictable outcome.

Annals of Plastic Surgrey

Lippincott, Williams, Wilkins

Surgical treatment of lymphedema of the penis and scrotum.

Aug 2006

Modolin M, Mitre AI, da Silva JC, Cintra W, Quagliano AP, Arap S, Ferreira MC.


Plastic Surgery/Urology Faculty of Medicine, University of São Paulo.


PURPOSE: Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region.

MATERIALS AND METHODS: Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface.

RESULTS: Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema.

CONCLUSIONS: The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.


The Charles procedure: misquoted and misunderstood since 1950.

Dec. 2006

Dumanian GA, Futrell JW.


Division of Plastic and Reconstructive Surgery, Northwestern University, Chicago, Ill, USA.


The Charles procedure, named for Sir Richard Henry Havelock Charles, is an eponym for a surgical treatment of leg lymphedema. Sir Havelock led a fascinating life, with his travels taking him to India, the Afghan territories, and the Court of King George V of England. At the turn of this century, Sir Havelock published material describing a series of 140 consecutive patients treated successfully for scrotal lymphedema. In a book chapter published a decade later, entitled “Elephantiasis Scroti,” Sir Havelock briefly described the treatment of leg lymphedema but did not document a single successful case report. The name of Sir Havelock Charles was absent from the literature until 1950, when Sir Archibald McIndoe attributed the treatment of leg lymphedema with radical excision and skin grafting to Sir Havelock. References to Charles for the treatment of leg lymphedema have proliferated since that time.

Plastic and Reconstructive Surgery

Lippincott, Williams, Wilkins

Modified Charles operation for primary fibrosclerotic lymphedema.

Mar 1994

Mavili ME, Naldoken S, Safak T.


Department of Plastic and Reconstructive Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey.

Abstract Radical excision of lymphedematous tissue with skin grafting (Charles operation) may be required for patients with advanced fibrosclerotic lower extremity lymphedema. Complications of this procedure include papillomatosis, 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 seemingly connects the superficial dermal lymphatics with subfascial deep lymphatics thereby facilitating lymph drainage and minimizing lymphedema accumulation and the complications outlined above. We have now treated 4 patients with advanced primary fibrosclerotic lymphedema using this modified technique. Not only were the patients improved in appearance and function with less trophic changes, but lymphscintigraphy using 99mTc-dextran also suggested improved interstitial tracer transport.}PubMed

Charles procedure for lymphedema: a warning.

Feb 1980

Miller TA.


Five patients with lower extremity lymphedema treated by subcutaneous excision and split-thickness graft resurfacing (from the opposite extremity) have been followed up. Three of these patients underwent amputation of the leg because of exophytic changes within the grafted skin, chronic cellulitis and skin breakdown. Resurfacing with a split-thickness graft causes a deformity that is significantly worse than the original lymphedema. In the Charles procedure (subcutaneous and deep fascial excision followed by full-thickness grafts), deep muscle fascia should be excised with the subcutaneous tissue and the extremity resurfaced with more durable full-thickness grafts taken from the excised tissue. However, the risks of graft failure should be considered. Over the past 9 years, 25 patients with lymphedema have been successfully managed by staged subcutaneous excision beneath flaps. This procedure safely provides consistent reduction in size, improvement in function and very satisfactory esthetic results. In the author's opinion the Charles procedure is therefore preferred for treating lymphedema of the extremity.


Lymphedema Debulking Surgery on a 2 year old

In our Children with Lymphedema Group, we recently had a discussion on this and one of our members sent the following post. It is one of those rare instances when I am left speechless. I feel such anger and sadness in what has been done to a prescious little two year old girl.

“I have not read what others have posted yet because I read emails in order of first received, but I am guessing that you are getting a lot of responses “against” debulking surgeries. Not having any experience with these procedures myself, I communicate with a mother whose 9-year old daughter is now unable to walk (probably for life) because of repeated surgeries (including debulking) that she has undergone at the insistence of doctors who promised things they could not deliver. I actually don’t know what to say to this poor woman when she tells me that her daughter’s leg is permanently oozing lymphatic fluid and that she changes the dressings on her legs every few hours because they are soaking wet. She tells me that she cries every day and blames herself for inflicting soooo much pain and agony on her daughter. She said that before the first surgery (age 2) her daughter was able to walk. Up to that point, her daughter’s LE had not been treated properly (MLD, bandaging, compression, etc…) so her right leg was pretty big and she was desperate to try anything that was a cure or fix, but 6 years later and many, many surgeries to correct each previous one, her daughter is permanently using a wheelchair and has to be home schooled because her leg is worse than she can even explain to me. After so many surgeries (who only knows what combination of different surgeries she has had), her right leg/foot is now shorter (doesn’t reach the floor) and her foot is turned completely in (not facing straight out) so she can not plant her foot on the ground. Oh and her foot is also completely limp (apparently they must have damaged muscle and tendons and bones too). So what I’m trying to say is to be very careful about what a doctor claims to be able to do because you may end up making an already difficult situation completely tragic. If debulking surgeries worked, all LE patients would be in line to have them done and there would be no need for the tedious (but effective) treatments such as MLD and daily bandaging and compression garments. I would love to be able to offer Sophie a quick fix, even if it entailed a surgery and recovery, but any reputable therapist will not even humor you by speaking of these procedures. Please use your “Mommy judgment” and don’t rush into anything. If you speak Spanish, I’m sure this mother would be willing to speak to you and offer some advice as well. Unfortunately for her, hind sight was 20/20 and now she regrets her decisions every day of her life.”

From a mom in our Children with Lymphedema Group

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charles_procedure.txt · Last modified: 2013/01/05 07:37 by Pat O'Connor