title: The diagnostic and surgical challenges of massive localized lymphedema.
abstract: BACKGROUND
  Massive localized lymphedema (MLL) is a rare entity first described in 1998 in patients with morbid obesity; the incidence is rising with the increased prevalence of morbid obesity. This report defines the clinical presentation and surgical challenges in 6 patients with MLL.
  
  
  METHODS
  The MLL in 6 patients with morbid obesity (weight range 270 to 585 lbs) involved the thigh in 3 patients, the calf in 1 patient, and the abdomen in 2 patients. The time from onset to presentation averaged 3 years (range 1 to 8 years). Two thigh lesions precluded ambulation because both legs could not be on the ground simultaneously; the 2 abdominal lesions were too heavy to permit ambulation.
  
  
  RESULTS
  The surgical excision required the use of pulleys to elevate the MLL tissues, which, on excision, weighed between 24 and 78 lbs. A long oval horizontal incision and a long transverse incision were used for the 2 abdominal lesions. Long horizontal oval limb incisions with multiple perpendicular cross incisions had to be used to excise MLL in the 4 limb lesions. In 2 cases, the vessel-sealing device was employed successfully for dissecting subcutaneous edematous tissue. Loose wound closure permitted postoperative lymph leakage, which continued for 3 to 8 weeks. The histology demonstrated fibrotic lymphatic tissue with vascular and lymphatic proliferation and edema; all patients did well.
  
  
  CONCLUSIONS
  MLL is rare and is best treated by surgical excision facilitated by pulleys and imaginative incisions to obtain primary closure. Long-term follow-up is necessary to assess for subsequent liposarcoma or angiosarcoma.
authors.affiliation: Department of Surgery, Wayne State University/Detroit Medical Center, 4201 St. Antoine Street, Detroit, MI 48201, USA.
authors.forename: Furrukh
authors.initials: F
authors.lastname: Jabbar
authors.affiliation: Department of Surgery, Wayne State University/Detroit Medical Center, 4201 St. Antoine Street, Detroit, MI 48201, USA.
authors.forename: Ziyad S
authors.initials: ZS
authors.lastname: Hammoudeh
authors.affiliation: Department of Surgery, Wayne State University/Detroit Medical Center, 4201 St. Antoine Street, Detroit, MI 48201, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Bachusz
authors.affiliation: Department of Surgery, Wayne State University/Detroit Medical Center, 4201 St. Antoine Street, Detroit, MI 48201, USA.
authors.forename: Anna M
authors.initials: AM
authors.lastname: Ledgerwood
authors.affiliation: Department of Surgery, Wayne State University/Detroit Medical Center, 4201 St. Antoine Street, Detroit, MI 48201, USA. Electronic address: clucas@med.wayne.edu.
authors.forename: Charles E
authors.initials: CE
authors.lastname: Lucas
mesh_terms: D000005:Abdomen; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007866:Leg; D008209:Lymphedema / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications*; D012720:Severity of Illness Index; D013514:Surgical Procedures, Operative / Q000379:methods*
keywords: Massive localized lymphedema; Presentation; Surgical challenges