The Use of a Dermal Regeneration Template for Total Subcutaneous Excision of Lymphedema

Introduction: In the last two decades some new surgical methods for lymphoedema treatment are used at Department of Plastic Surgery and Burns in Ljubljana.

As physiological operations, we have experiences by lymphatic reconstruction, when a new lymphatic tissue is microsurgicaly implanted into lymphoedematous limb. While for ablative surgery, we usually perform a liposuction or total excisions using dermal regeneration template (DRT).

Total subcutaneous excision, originally described by Charles (1912), and commonly used since then, this operation is an extensive procedure that removes all of the skin, subcutaneous tissue - except in the foot and region overlying the calcaneal tendon - and deep fascia. The bared muscle is covered by split or full thickness grafts. Although split thickness grafts are technically easier in comparison to full thickness graft and initially appear satisfactory. Late scarring is marked and the grafts ulcerate and develop a severe hyperkeratotic, weeping, chronically infected dermatitis. Long-term postoperative results are bad with substantial scarring and lymphatic fibrosis.

Methodology and Material: We operated 7 patients by DRT usage. They underwent an ablative surgery of subcutaneous tissue of a lower leg. After debridement a dermal regeneration templates (DRT) were used to cover exposed area. Grafts where protected by a foils dressing and secondary dressing. After, nearly 3 weeks, silicon layer was peeled off and neodermis was covered with autologous split thickness skin grafts. All the surgery and dressings were done according to producer’s guidelines orders.

Results: No infection or inflammation was found and primary ingrowths of templates were present, as also of skin grafts. Some areas showed granulation tissue in-between grafts. Later, skin covercle showed a suitable result, without a moose like appearance. After six weeks, patient started to wear elastic hoses.

Conclusions: Simple skin grafting represents unstable epithelial layer, while using DRT represents better quality of a skin cover. In chronic, long-standing lymphedema, where there is a substantial element of an extensive fibrosis, this may be the best technically feasible procedure available