title: Debulking surgery for elephantiasis nostras with large ectatic podoplanin-negative lymphatic vessels in patients with lipo-lymphedema.
abstract: OBJECTIVE
  Elephantiasis nostras is a rare complication in advanced lipo-lymphedema. While lipedema can be treated by liposuction and lymphedema by decongestive lymphatic therapy, elephantiasis nostras may need debulking surgery.
  
  
  METHODS
  We present 2 cases of advanced lipo-lymphedema complicated by elephantiasis nostras. After tumescent microcannular laser-assisted liposuction both patients underwent a debulking surgery with a modification of Auchincloss-Kim's technique. Histologic examination of the tissue specimen was performed.
  
  
  RESULTS
  The surgical treatment was well tolerated and primary healing was uneventful. After primary wound healing and ambulation of the patients, a delayed ulceration with lymphorrhea developed. It was treated by surgical necrectomy and vacuum-assisted closure leading to complete healing. Mobility of the leg was much improved. Histologic examination revealed massive ectatic lymphatic vessels nonreactive for podoplanin.
  
  
  CONCLUSIONS
  Debulking surgery can be an adjuvant technique for elephantiasis nostras in advanced lipo-lymphedema. Although delayed postoperative wound healing problems were observed, necrectomy and vacuum-assisted closure achieved a complete healing. Histologic data suggest that the ectatic lymphatic vessels in these patients resemble finding in podoplanin knockout mice. The findings would explain the limitations of decongestive lymphatic therapy and tumescent liposuction in such patients and their predisposition to relapsing erysipelas.
authors.affiliation: Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
authors.forename: Uwe
authors.initials: U
authors.lastname: Wollina
authors.affiliation: Department of Physical Therapy and Rehabilitative Medicine, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
authors.forename: Birgit
authors.initials: B
authors.lastname: Heinig
authors.affiliation: Institute of Pathology "Georg Schmorl", Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
authors.forename: Jaqueline
authors.initials: J
authors.lastname: Schönlebe
authors.affiliation: Department of Anesthesiology and Intensive Medical Care, Emergency Medicine and Pain Management, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Nowak
keywords: adjuvant debulking surgery; decongestive lymphatic therapy; elephantiasis nostras; lipo-lymphedema; tumescent liposuction
references.citation: Int Angiol. 2012 Aug;31(4):316-29
references.pmid: 22801397
references.citation: EMBO J. 2003 Jul 15;22(14):3546-56
references.pmid: 12853470
references.citation: ANZ J Surg. 2007 Sep;77(9):738-41
references.pmid: 17685948
references.citation: Cancer. 1998 Dec 15;83(12 Suppl American):2840-2
references.pmid: 9874409
references.citation: G Ital Dermatol Venereol. 2010 Apr;145(2):151-9
references.pmid: 20467389
references.citation: Hautarzt. 2012 Aug;63(8):627-33
references.pmid: 22821152
references.citation: J Cutan Pathol. 2009 Dec;36(12):1293-8
references.pmid: 19281484
references.citation: Indian J Anaesth. 2011 Mar;55(2):111-5
references.pmid: 21712864
references.citation: Plast Reconstr Surg. 1998 Sep;102(4):1058-67; discussion 1068
references.pmid: 9734424
references.citation: J Wound Care. 2010 Jan;19(1):15-7
references.pmid: 20081569
references.citation: J Cutan Med Surg. 2006 Jan-Feb;10(1):7-10
references.pmid: 17241565
references.citation: Ann Plast Surg. 2012 Mar;68(3):303-7
references.pmid: 21629090
references.citation: Lymphology. 1998 Dec;31(4):156-72
references.pmid: 9949387
references.citation: Lymphology. 2013 Mar;46(1):1-11
references.pmid: 23930436
references.citation: Int Angiol. 2008 Oct;27(5):389-95
references.pmid: 18974701
references.citation: Handchir Mikrochir Plast Chir. 2012 Dec;44(6):348-54
references.pmid: 23283813
references.citation: J Plast Reconstr Aesthet Surg. 2013 Mar;66(3):390-6
references.pmid: 23107617
references.citation: Lymphology. 2011 Dec;44(4):178-82
references.pmid: 22458119
references.citation: Eplasty. 2013;13:ic24
references.pmid: 23409215
references.citation: J Dtsch Dermatol Ges. 2004 Mar;2(3):181-6
references.pmid: 16281634
references.citation: Lymphology. 1998 Dec;31(4):190-4
references.pmid: 9949391
references.citation: J Dtsch Dermatol Ges. 2011 Jan;9(1):33-40
references.pmid: 21166777
references.citation: Semin Thromb Hemost. 2010 Apr;36(3):352-61
references.pmid: 20490985
references.citation: Int J Low Extrem Wounds. 2003 Sep;2(3):173-6
references.pmid: 15866844