Preservation of toes in advanced lymphedema: an important step in the control of infection.

In advanced lymphedema, the most important goal of treatment is the control or eradication of infection. Toes are the major cause of infection mainly due to lack of space at the webs. The fibrosis of the soft tissue with impaired circulation of the toes certainly contribute to infection of the toes, foot, and even proximal to the leg. Between 2004 and 2008, 20 patients with severe lymphedema and fibrosis of lower limbs were treated with Charles' procedure and included in this study. The toes were preserved. Excisional therapy is the only choice to decrease the lymphatic load and control the infection. The toes can be preserved if there is only swelling without previous cellulites or verrucous hyperkeratosis and neither deformity nor osteomyelitis of the toes. The surgical technique to treat the toes includes (1) excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its paratenon, to facilitate the take of skin graft, and (2) preservation of skin flaps at the web spaces. This avoids contracture at the web spaces and crowding of the toes, improves foot hygiene, and hence prevents infection. Proper aesthetic and functional results were obtained in all patients and 18 of 20 patients have been free of recurrent infection at 3-years follow-up. In the treatment of advanced lymphedema of the lower extremity, the toes are the major determinant of future infection after surgery. For preservation of toes, careful selection of patients and correct surgical procedure are essential for success.