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Modified Charles Procedure

The Modified Charles Procedure is a radical excisional (ablative) operation for end-stage lymphedema (ISL Stage II–III / elephantiasis) — complete excision of skin and subcutaneous tissue down to the deep fascia, followed by resurfacing with skin grafts. It remains the most aggressive debulking operation in the lymphedema armamentarium and is reserved for the most severe cases where physiologic procedures (LVA, VLNT) and conservative therapy have failed or are unavailable.[1][2][3]

In the urologic context it is the most commonly performed excisional procedure for penoscrotal elephantiasis, though combined excisional + physiologic procedures (CHASCIP, 3R, VLNT) are increasingly favored.[14][18][20]

For the clinical condition see Giant Penoscrotal Lymphedema; for the broader framework see Genital Lymphedema.

Historical Background​

First outlined by Sir Havelock Charles in 1912 for lower-limb lymphedema (without a published case), the procedure was resurrected and popularized in the 1950s. Modern "Modified Charles" refers to refinements that improve outcome and reduce morbidity — NPWT with delayed grafting, combination with physiologic procedures, and systematic perioperative protocols.[2]

Indications​

  • Late-stage (ISL Stage II–III) lower-extremity lymphedema with irreversible fibroadipose deposition, refractory to conservative therapy and physiologic microsurgery.[1][3][4]
  • Lymphostatic elephantiasis with recurrent cellulitis, functional impairment, immobility.[5][6]
  • Penoscrotal elephantiasis — modified for genital application.[7]
  • Both primary and secondary lymphedema, including filarial and post-oncologic causes.[5][8]

Surgical Technique — Core Principles​

  1. Excision. Circumferential skin and subcutaneous tissue excised down to the deep muscular fascia; fascia may be trimmed.[8][9]
  2. Resurfacing.
    • Full-thickness grafts harvested from the excised specimen — more durable; preferred in the original Charles description.[10]
    • Split-thickness skin grafts (STSG) — more commonly used in modern practice from the contralateral thigh. Early reports warned that STSG resurfacing can cause exophytic skin changes, chronic cellulitis, and skin breakdown — 3/5 patients in one historical series ultimately required amputation.[10]

Key Modifications​

ModificationDetail
NPWT / VAC + delayed grafting (5–7 d)Promotes a clean granulating bed and improves take to ~100% vs ~88% historical.[8][11]
CHAHOVA (Charles + Homan's + VLNT)Combines Charles with Homan's wedge excisions of the thigh and vascularized lymph node transfer to address both tissue bulk and lymphatic function.[9]
Radical Reduction with Perforator Preservation (RRRP) + distal LVACircumference reduction 75–90% across limb segments.[12]
Platelet-rich plasma (PRP)Improves graft quality and lymph-node-flap integration.[9]
Toe managementIntegrated as part of CHAHOVA comprehensive treatment.[9]

Outcomes — Lower Extremity​

  • Volume / circumference reduction. Immediate and dramatic. Graft take ~88% historical; ~100% with NPWT.[5][11]
  • Function. Patients consistently exceed preoperative activity levels; self-reported mobility same or improved at 6 mo.[1][6]
  • Satisfaction. High overall — especially with NPWT-delayed-grafting modification.[8]
  • Cellulitis. Reduced overall, but remains the most common postoperative complication (~18.5%).[6]

Complications​

ComplicationDetail
Significant blood loss / fluid shiftsMay require ICU admission; perioperative fluid management essential.[1]
Wound infectionMost common complication; prophylactic antibiotics recommended.[1][2][3]
Graft failure / regrafting3/8 (37.5%) required regrafting in one modified series.[4]
Exophytic skin changesParticularly with STSG; chronic breakdown risk.[5]
Prolonged hospitalizationMean 21–54 days across series.[2][3]
Secondary procedures59.3% required further minor surgery after discharge in one series.[3]
Amputation (historical)3/5 STSG patients in an early series — underscores the importance of graft-type selection.[5]
Recurrence~9% recurrence requiring repeat excision (penoscrotal series).[6]

Postoperative Care​

  • Compression therapy mandatory long-term to maintain volume reduction.[6]
  • Limb elevation in the immediate postoperative period.
  • NPWT × 5–7 d over grafts in the modified technique.[8][11]
  • Staged regrafting for graft-loss areas.
  • Average inpatient stay 21–54 days.[5][6]

Urologic Application — Penoscrotal Elephantiasis​

Etiology​

Acquired (most common)Congenital / primary
Filariasis (endemic tropics / subtropics); iatrogenic after inguinal / pelvic lymphadenectomy + RT for GU / gynecologic malignancy; chronic infection; morbid obesity (MLL).[3][4][5][6][7]Primary lymphatic dysplasia — up to 84% in some European series.[8]

McDougal classification — surgical decision​

  • Self-limited without permanent pathological change → conservative therapy.
  • Chronic with irreversible skin / subcutaneous change → excisional surgery; the Modified Charles procedure with STSG is the most effective approach for the most severe forms.[3]

The Ehrl 2023 treatment-oriented classification for giant penoscrotal lymphedema standardizes whether resection alone vs resection + VLNT is appropriate.[9]

Operative protocol​

  1. Scrotal excision. All diseased scrotal skin and subcutaneous tissue excised while preserving testes, spermatic cords, and tunica vaginalis. No orchiectomy needed even for massive specimens (up to 61 kg in one series).[7]
  2. Scrotoplasty. Reconstruction with lateral and posterior mobilized skin flaps; midline suture simulating the raphe.[1][6]
  3. Penile reconstruction. Excise diseased penile skin circumferentially; resurface with STSG in a zigzag ventral suture to prevent contracture. Preserve healthy inner prepucial skin for the distal shaft if available.[1][6]
  4. Hydrocoelectomy. Concomitant in ~43% with associated hydrocele.[8]
  5. NPWT modification. Negative-pressure dressing over the grafted penis × 5–7 days.[4][11]

Outcomes — urologic​

  • Singh 2011 (n = 48 filarial) — 100% satisfactory cosmesis; improved standing voiding, ambulation, sexual activity at median 48 mo follow-up.[6]
  • Modolin 2006 (n = 17) — symptom regression; improved hygiene, ambulation, voiding, intercourse over 6 mo–6 yr.[1]
  • Salako 2018 (n = 11, sub-Saharan Africa) — hematoma 27.3%, SSI 18.2%, recurrence 9.1%; combined urology + plastics team essential.[7]
  • Wisenbaugh 2018 MLL (n = 11) — QoL 1.3 → 7.7; most patients gained 5.2 kg postoperatively (without weight-loss program).[7]
  • Torio-Padron 2015 (n = 51 integrated CDP) — 6% revision rate; GBI improvement in general functioning and physical health.[8]

Complication-rate comparison (Guiotto SR)​

ApproachComplication rate
Excision + primary closure or graft~10%
Excision + flap reconstruction54.2%
LVA alone9%
[5]

Evolving — Beyond classic Modified Charles​

ProcedureHighlight
CHASCIP (Charles + bilateral SCIP lymphatic flap, Ciudad 2025)n = 8, 0% recurrence at 34 mo; sexual dysfunction 87.5% → 0%.[20]
3R (Radical Reduction + Reconstruction; Yamamoto 2022)n = 7; 0% complications, 0% recurrence; GLS 6.7 → 0.3; no postop compression required.[18]
VLNT into scrotum (Ehrl 2023)n = 9 (5 VLNT); scrotal VLNT improved lymphatic transport; 0% recurrence at 49 mo.[9]
Abdelfattah complete functional lymphatic-system pedicled transfern = 26; 100% flap survival; cellulitis dramatically reduced (p < 0.001).[19]

These address a fundamental limitation of the classic Modified Charles — while it effectively debulks, it does not restore lymphatic drainage, leaving patients vulnerable to recurrence and lymphorrhea. Adding lymphatic flap transfer delivers both durable soft-tissue coverage and functional lymphatic restoration.[18][19][20]

Multidisciplinary Approach​

Penoscrotal lymphedema reconstruction is best performed by a combined urology + plastics team.[4] The urologist preserves testicular and urethral function; the plastic surgeon optimizes soft-tissue reconstruction and (increasingly) microsurgical lymphatic restoration.

Modern Context and Coverage​

The Charles procedure is classified as an ablative / reductive technique, distinct from physiologic procedures (LVA, VLNT).[3][13] Despite its irreplaceable role in end-stage disease where only debulking can remove fibroadipose tissue, only 19.4% of US health-insurance companies cover debulking procedures, and many require a prior trial of conservative therapy.[14] The trend is toward integrated strategies that combine the Charles procedure with physiologic microsurgery to optimize both volume reduction and lymphatic restoration.[4][9][12]

Key Takeaway​

The Modified Charles Procedure remains a life-changing intervention for the most extreme lymphedema. Modern modifications — particularly NPWT with delayed grafting, combination with physiologic procedures (CHAHOVA in the limb, CHASCIP / 3R / VLNT in the genitalia), and systematic perioperative protocols — have substantially improved the predictability and safety of outcomes compared with the historical procedure.[1][8][9][6][18][20]

See Also​

References​

1. Hassan K, Chang DW. The Charles procedure as part of the modern armamentarium against lymphedema. Ann Plast Surg. 2020;85(6):e37–e43. doi:10.1097/SAP.0000000000002263

2. Lurie F, Malgor RD, Carman T, et al. AVF / AVLS / SVM expert opinion consensus on lymphedema diagnosis and treatment. Phlebology. 2022;37(4):252–266. doi:10.1177/02683555211053532

3. Garza R, Skoracki R, Hock K, Povoski SP. A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. BMC Cancer. 2017;17(1):468. doi:10.1186/s12885-017-3444-9

4. Chen J, Chen Z, Wu X, et al. Integrated surgical treatment: a new model for treating secondary extremity lymphedema based on algorithms. Front Oncol. 2025;15:1676803. doi:10.3389/fonc.2025.1676803

5. Dandapat MC, Mohapatro SK, Mohanty SS. Filarial lymphoedema and elephantiasis of lower limb: a review of 44 cases. Br J Surg. 1986;73(6):451–453. doi:10.1002/bjs.1800730612

6. Karri V, Yang MC, Lee IJ, et al. Optimizing outcome of Charles procedure for chronic lower-extremity lymphoedema. Ann Plast Surg. 2011;66(4):393–402. doi:10.1097/SAP.0b013e3181d6e45e

7. Salako AA, Olabanji JK, Oladele AO, et al. Surgical reconstruction of giant penoscrotal lymphedema in sub-Saharan Africa. Urology. 2018;112:181–185. doi:10.1016/j.urology.2016.09.064

8. van der Walt JC, Perks TJ, Zeeman BJ, Bruce-Chwatt AJ, Graewe FR. Modified Charles procedure using negative-pressure dressings for primary lymphedema: a functional assessment. Ann Plast Surg. 2009;62(6):669–675. doi:10.1097/SAP.0b013e318180cd24

9. Ciudad P, Agko M, Huang TCT, et al. Comprehensive multimodal surgical treatment of end-stage lower-extremity lymphedema with toe management — the combined Charles, Homan's, and VLNT (CHAHOVA) procedures. J Surg Oncol. 2019;119(4):430–438. doi:10.1002/jso.25356

10. Miller TA. Charles procedure for lymphedema: a warning. Am J Surg. 1980;139(2):290–292. doi:10.1016/0002-9610(80)90276-7

11. Stokes TH, Follmar KE, Silverstein AD, et al. Use of negative-pressure dressings and split-thickness skin grafts following penile-shaft reduction and reduction scrotoplasty in the management of penoscrotal elephantiasis. Ann Plast Surg. 2006;56(6):649–653. doi:10.1097/01.sap.0000202826.61782.c9

12. Ciudad P, Vargas MI, Bustamante A, et al. Combined radical reduction with preservation of perforators and distal LVA for advanced lower-extremity lymphedema. Microsurgery. 2020;40(3):417–418. doi:10.1002/micr.30569

13. Schaverien MV, Coroneos CJ. Surgical treatment of lymphedema. Plast Reconstr Surg. 2019;144(3):738–758. doi:10.1097/PRS.0000000000005993

14. Lynn JV, Hespe GE, Akhter MF, et al. Cross-sectional analysis of insurance coverage for lymphedema treatments in the United States. JAMA Surg. 2023;158(9):920–926. doi:10.1001/jamasurg.2023.2017

15. Modolin M, Mitre AI, da Silva JC, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinics (Sao Paulo). 2006;61(4):289–294. doi:10.1590/s1807-59322006000400003

16. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A systematic review of outcomes after genital lymphedema surgery. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875

17. McDougal WS. Lymphedema of the external genitalia. J Urol. 2003;170(3):711–716. doi:10.1097/01.ju.0000067625.45000.9e

18. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: SCIP lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011

19. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of advanced male genital lymphedema with a complete functional lymphatic-system pedicled transfer. Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006

20. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. Surgical management of genital lymphedema using the combined Charles' procedure and lymphatic SCIP flap transfer (CHASCIP). Microsurgery. 2025;45(5):e70075. doi:10.1002/micr.70075

21. Singh V, Sinha RJ, Sankhwar SN, Kumar V. Reconstructive surgery for penoscrotal filarial lymphedema. Urology. 2011;77(5):1228–1231. doi:10.1016/j.urology.2010.10.026

22. Torio-Padron N, Stark GB, Földi E, Simunovic F. Treatment of male genital lymphedema: an integrated concept. J Plast Reconstr Aesthet Surg. 2015;68(2):262–268. doi:10.1016/j.bjps.2014.10.003

23. Wisenbaugh E, Moskowitz D, Gelman J. Reconstruction of massive localized lymphedema of the scrotum. Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063

24. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema — what to do? J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586