{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T05:43:21Z","timestamp":1768283001495,"version":"3.49.0"},"reference-count":63,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T00:00:00Z","timestamp":1737331200000},"content-version":"vor","delay-in-days":19,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Microsurgery"],"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:title>ABSTRACT<\/jats:title><jats:p>The Charles procedure (CP) is a potentially devastating treatment; however, in cases of an end stage of untreated or improperly treated lymphedema, it is the ultimate surgical therapy. As a life\u2010saving solution, it quickly relieves patients with giant, hypertrophic extremities, mostly in ambulation and hygiene maintenance. Nevertheless, long\u2010term results may disappoint both doctors and patients, who struggle with social stigma, the need for lifelong compression, massive lymphoedema in the distal parts of the feet, badly fitting shoes, excessive skin fibrosis, severe keratinization of skin\u2010grafted surfaces, periodic lymphorrhea from the resected areas, or acute and chronic inflammation. For these reasons, patients may seek further surgical help, even many years after treatment. This article describes findings in fluorescent lymphography with indocyanine green (ICG\u2010L) in four patients (49, 56, 56\u2009years old females and 35\u2009years old males) after CP and outcomes of treatment with lymphaticovenous anastomosis (LVA). In all patients, nonresected areas of the dorsum of the feet showed massive lymphedema stage II to III with dermal backflow (DB). In two patients, resected and skin\u2010grafted areas showed deep subfascial lymphatics with lazy flow and no DB. In the remaining two cases, resected areas showed massive DB. Patients were reluctant to undergo further extensive surgical treatment with lymph node transfers due to the trauma experienced after CP. Since they still struggle with residual lower extremity lymphedema in unresected areas of the lower limbs, we performed minimally invasive, physiologic LVA surgeries in their feet, and in one patient in proximal thighs. In all cases, the postoperative course was uneventful. The treatment brought relief, reducing the circumference of the feet by ~2\u2009cm, and allowed the return to previously used shoes in a follow\u2010up of 18\u201336\u2009months. This is the first report of ICG\u2010L findings in CP patients, who benefit from minimal invasive LVA surgery. This information might help improve the life quality of patients after CP.<\/jats:p>","DOI":"10.1002\/micr.70015","type":"journal-article","created":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T09:17:35Z","timestamp":1737364655000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Long\u2010Term Follow\u2010Up After the Charles Procedure: Possibilities for Minimally Invasive Reconstructive Lymphedema Surgery With Lymphaticovenous Anastomosis: A Report of Four Cases"],"prefix":"10.1002","volume":"45","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3608-3472","authenticated-orcid":false,"given":"Natalia Ewa","family":"Krzesniak","sequence":"first","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Centre of Postgraduate Medical Education Prof. W. Orlowski Memorial Hospital  Warsaw Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9293-6129","authenticated-orcid":false,"given":"Marzanna","family":"Zaleska","sequence":"additional","affiliation":[{"name":"Department of Applied Physiology Medical Research Institute, Polish Academy of Sciences  Warsaw Poland"},{"name":"Department of Vascular Surgery Central Clinical Hospital  Warsaw Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8027-7023","authenticated-orcid":false,"given":"Balazs","family":"Mohos","sequence":"additional","affiliation":[{"name":"Heart and Vascular Center Semmelweis University  Budapest Hungary"},{"name":"Plastic and Reconstructive Surgery, Department of Surgery County Hospital Veszprem  Veszprem Hungary"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5118-4696","authenticated-orcid":false,"given":"Manon","family":"Czedik\u2010Eysenberg","sequence":"additional","affiliation":[{"name":"Plastic and Reconstructive Surgery, Department of Surgery Hospital of Divine Savior  Vienna Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2682-1720","authenticated-orcid":false,"given":"Michaela","family":"Krammel","sequence":"additional","affiliation":[{"name":"TZOU Medical  Vienna Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3903-801X","authenticated-orcid":false,"given":"Chieh\u2010Han John","family":"Tzou","sequence":"additional","affiliation":[{"name":"Plastic and Reconstructive Surgery, Department of Surgery Hospital of Divine Savior  Vienna Austria"},{"name":"TZOU Medical  Vienna Austria"},{"name":"Faculty of Medicine Sigmund Freud University  Vienna Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,1,20]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"119","article-title":"Plantar Lymphatic Network","volume":"51","author":"Amore M.","year":"2018","journal-title":"Lymphology"},{"key":"e_1_2_8_3_1","volume-title":"Plastic Surgery Key. 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