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Modified Charles Procedure

“Modified Charles” describes several excisional operations, not one uniform reconstruction. In limb surgery it usually denotes extensive removal of diseased skin and subcutaneous tissue followed by grafting. In the genital series of Modolin and colleagues, it meant excision followed by local scrotal reconstruction and penile split-thickness skin grafting. The operative report should state the actual excision, tissues preserved and method of coverage.[1][2]

This page concerns penoscrotal lymphedema. See debulking scrotoplasty for the broader operation and genital lymphedema for diagnosis and treatment selection.

Selection and Planning​

Excision can address disabling fibrotic enlargement, diseased skin, lymphorrhea and recurrent infection when conservative measures do not adequately control the problem. It does not require every patient to fail LVA and VLNT first. Reconstructive choice depends on the residual healthy tissue, functional lymphatics, prior surgery or radiation, comorbidity and goals. ISL stages were formulated for the extremities; “stage II” alone is not a genital indication for radical resection.[3]

Before surgery:

  • Assess the cause, skin condition, extent of penile involvement, previous groin treatment and possible recurrent malignancy. Treat active infection and optimize modifiable perioperative risks.
  • Use decongestive therapy when feasible to address the fluid component and skin care. A fixed inpatient course is not mandatory for every genital operation.
  • Plan exposure of the penis, urethra, testes and cords before committing to the resection. Identify usable local skin and a backup coverage option; do not assume that all remaining skin is healthy.
  • Explain the possibilities of wound breakdown, graft loss, altered sensation, recurrence and further surgery. The objective is functional improvement, with ongoing lymphedema care individualized afterward.[1][3][4]

Genital Operative Principles​

  1. Define the diseased envelope and protect deeper structures. Excise affected skin and fibrotic subcutaneous tissue while identifying and protecting viable testes, spermatic cords, penile structures and urethra. The limb instruction to excise to or through deep muscular fascia is not a genital dissection rule. Preserve useful vascularized tissue rather than applying circumferential fascial stripping by default.[1]
  2. Reconstruct the scrotum according to the defect. Healthy adjacent scrotal or perineal skin may allow tension-free closure or local flaps. If it does not, choose a graft or another flap based on the recipient bed and coverage requirements. The term “modified Charles” does not require scrotal grafting.[1][4]
  3. Resurface the penis when its skin must be removed. A penile STSG is an established option. Provide a vascularized bed, adequate coverage for shaft expansion, hemostasis and secure fixation without constriction. Modolin's ventral zigzag suture is a described technique, not proof of prevention of contracture. See penile skin grafting.[1]
  4. Treat associated pathology on its own merits. Assess a hydrocele, hernia or suspicious lesion rather than automatically performing hydrocelectomy or orchiectomy. Viable testes and their blood supply should be preserved when oncologically and technically appropriate.[1][4]
  5. Select the dressing and timing. Conventional bolsters and carefully applied negative-pressure dressings are options for graft fixation. Staged wound preparation and NPWT used over an already placed graft are different strategies; neither has a universal five-to-seven-day genital protocol.[5][6]
Do not transfer limb graft data to genital counseling

The historical five-patient series reporting three amputations involved legs, not genital reconstruction. It cannot establish that full-thickness grafts are universally safer than STSGs for the penis or scrotum. Similarly, limb graft-take percentages and hospital stays should not be presented as expected genital outcomes.[7]

What the Genital Evidence Shows​

The literature largely consists of small, uncontrolled series with different causes, disease severity and reconstructive methods. It supports the feasibility of substantial functional improvement, but cannot reliably rank operations or establish a universal recurrence rate.

ReportFindings and limits
Modolin 2006Seventeen patients underwent excision, local scrotoplasty and penile STSG. Follow-up ranged from six months to six years. Function and hygiene improved; one patient previously treated with penile-cancer lymphadenectomy and radiotherapy developed recurrent scrotal lymphedema. Outcomes were not a controlled comparison or a validated sexual-function assessment.[1]
Salako 2018Eleven of 19 presenting patients underwent surgery. Three developed hematoma, two superficial infection and one recurrence within 24 months. These are cohort-specific observations, not an expected complication percentage for every patient.[8]
Stokes 2006Eight men underwent penile degloving, reduction scrotoplasty and penile STSG. The six most recent cases received negative-pressure graft dressings and had complete reported graft take. This small series does not prove superiority over another dressing or guarantee 100% take.[6]

The van der Walt report often cited for delayed grafting after five to seven days of NPWT involved eight patients with severe primary limb lymphedema; three required additional grafting. It should not be conflated with the penile graft-bolster series above.[5]

Combining Excision With Lymphatic Reconstruction​

LVA, VLNT or a lymphatic SCIP flap may be considered in selected patients by an experienced lymphatic reconstruction team. These procedures aim to improve drainage in addition to reducing tissue bulk. Current genital evidence does not establish that adding them routinely is superior to a well-selected excisional reconstruction or that it eliminates compression, recurrence or donor-site morbidity.[3][4]

For example, the 2025 CHASCIP series combined excision with bilateral pedicled lymphatic SCIP flaps in eight men. At a mean 34-month follow-up no recurrence was observed, but two patients had postoperative complications—seroma/dehiscence in one and partial graft loss in another. There was no excision-only control group. Its favorable symptom scores are promising feasibility findings, not evidence of a new mandatory standard.[9]

Excision is reductive rather than a lymphatic bypass, but it is also too absolute to claim that drainage can never improve afterward. In a small genital MRL cohort, postoperative imaging showed reopening of functional pathways after excision. This observation does not establish a cure or validate imaging as a universal selection algorithm.[10]

Recovery and Follow-up​

Monitor perfusion, hematoma, infection, urinary drainage and graft/flap adherence. Dressing changes, mobilization, drains and catheter removal follow the actual reconstruction and wound condition; limb-series hospital stays are not a genital discharge requirement. Persistent skin disease, graft contraction, lymphorrhea or recurrent enlargement warrants reassessment.

Continue skin care and individualized support/compression with the lymphedema team when appropriate. A successful operation does not guarantee that all long-term therapy can stop. Equally, postoperative compression cannot be prescribed as an identical lifelong regimen for every genital graft or flap.[3][4]

References​

1. Modolin M, Mitre AI, da Silva JC, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinics. 2006;61:289–294. doi:10.1590/S1807-59322006000400003.

2. 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

3. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2023 consensus document. Lymphology. 2023;56:133–151. Consensus document.

4. Vignes S. Genital lymphedema after cancer treatment: a narrative review. Cancers. 2022;14:5809. doi:10.3390/cancers14235809.

5. 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

6. 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

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

8. 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

9. 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

10. Lu Q, et al. Assessment of the lymphatic system of the genitalia using magnetic resonance lymphography before and after treatment of male genital lymphedema. Medicine. 2016;95:e3755. doi:10.1097/MD.0000000000003755.