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Reduction operations
Four types of excisional operation have been described to reduce the size of the limb. The Sistrunk operation involves excision of a large wedge or ellipse of skin and subcutaneous tissue which is then closed primarily. Homan elevated skin flaps from the subcutaneous fat, excising the underlying subcutaneous tissue before resuturing the skin flaps in place. Thompson modified the Homan's operation by suturing one of the skin flaps to the deep fascia. Denudation of the superficial layers of the flap stops hair growth and prevents pilonidal sinus formation. The second flap is then sewn over the top of the denuded skin area. This operation has largely been abandoned: it leaves unsightly scars, it is often complicated by pilonidal sinus formation, and the results appear to be no better than those of the simpler Homan's procedure.
Both Homan's and Thompson's operations can be complicated by skin flap necrosis and poor healing, particularly at the corners of the flaps. Great care needs to be taken to maintain the blood supply of the flaps, which must not be cut too thin. Flap reduction of the calf and foot is normally combined with a Sistrunk operation on the thigh if the whole limb is to be reduced in size.
Charles invented an operation to remove the severely thickened skin in patients with filariasis. He excised all the diseased skin and the waterlogged subcutaneous tissue down to, and often including, the deep fascia from just above the ankle to just below the knee. The periosteum over the tibia was left intact and split skin grafts were then taken from normal donor skin (the opposite normal limb, or the abdomen, back, and buttocks) and used to cover the deep fascia or muscle. This operation produces the best reduction in limb size, but often at the expense of cosmesis. The ankle and knee area have to be carefully tailored to avoid a pantaloon effect, and thigh reduction is also often necessary. Some patients have a poor acceptance of split skin grafts and require multiple operations to achieve complete healing. Other patients develop severe hyperkeratotic scars with warty excrescences, which produce severe deformity in the operated limb. This can be treated by shaving off the warty nodules and thickened scars with a scalpel or skin graft knife; additional skin grafts are occasionally needed. However, final results are usually very satisfactory, especially in a grossly enlarged limb with very abnormal calf skin.
Summary
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