|Year : 2019 | Volume
| Issue : 4 | Page : 211-213
Use of avulsed skin flap as donor site for reconstruction of total forearm skin avulsion injuries
Burkay Akduman, Galip Gencay Ustun, Koray Gursoy, Ugur Kocer
Department of Plastic Reconstructive and Aesthetic Surgery, Ankara Training and Research Hospital, Altindag, Ankara, Turkey
|Date of Submission||13-Dec-2018|
|Date of Acceptance||05-Mar-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Burkay Akduman
Ankara Training and Research Hospital, Ulucanlar Cd. Ankara Egitim Ve Arastirma Hastanesi, 06230 Altindag, Ankara
Source of Support: None, Conflict of Interest: None
Avulsion injuries involving upper extremity are challenging in most cases. The musculoskeletal and main neurovascular parts on the injured region are unharmed. Even though the hand functions are maintained well, it is difficult to reconstruct large areas of defective skin. This specific case report demonstrates the mesh autograft methodology to successfully reconstruct the skin loss after a forearm skin avulsion injury.
Keywords: Avulsion Injuries, degloving, mesh graft, upper extremity
|How to cite this article:|
Akduman B, Ustun GG, Gursoy K, Kocer U. Use of avulsed skin flap as donor site for reconstruction of total forearm skin avulsion injuries. Turk J Plast Surg 2019;27:211-3
|How to cite this URL:|
Akduman B, Ustun GG, Gursoy K, Kocer U. Use of avulsed skin flap as donor site for reconstruction of total forearm skin avulsion injuries. Turk J Plast Surg [serial online] 2019 [cited 2019 Nov 20];27:211-3. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/211/267937
| Introduction|| |
Degloving injuries define the cases where skin and subcutaneous tissue to be injured leaving the subfascial tissues intact. Since the skin and subcutaneous tissue's vascular connection is lost, wide degloving injuries happen to be serious surgical problems. Although there are a number of different techniques described, each has limitations. Full-thickness skin grafts have limited donor site that might not be enough for the total closure of the defect, and split-thickness skin grafts have visible donor site scar and morbidity. Local or regional flap coverage is usually impossible and free flaps may be considered as overtreatment taking deep tissues such as muscles, nerves, and vessels maintaining integrity into account. Readaptation of avulsed flap usually ends up with partial flap loss. A relatively easy method without donor site morbidity is readaptation of avulsed flap as a mesh skin graft to the defect.
| Case Report|| |
A 41-year-old male patient was brought to emergency service with a degloving injury that spans from left forearm proximal elbow level to wrist fold, due to an avulsion injury caused by an industrial machine [Figure 1]. The skin and subcutaneous tissue on the dorsal face of the injured area were defective. While the tissue and subcutaneous tissue on the volar face were totally avulsed, only a small piece of skin of the wrist fold remained attached to fascia. There was no functional loss on the patient's wrist and fingers during the examination. After taking informed consent prior to treatment the patient was taken to operating room after tetanus prophylaxis. Under general anesthesia, to decrease the bacterial contamination, pressurized irrigation using 4 L of 0.9% saline was applied. After defatting of the avulsed flap which turns it into a skin graft, meshing was applied [Figure 2]. The meshed graft was designed and adapted to completely cover the injured area [Figure 3]. The resting splint was applied with the purpose of graft immobilization. Prophylactic antibiotic treatment was started after the operation and continued by applying wound dressing for the following term. All wounds were covered, and complete healing was accomplished [Figure 4], [Figure 5], [Figure 6], [Figure 7]. Functional capacity is fully preserved [Figure 8], [Figure 9], [Figure 10].
|Figure 1: Avulsion injury caused by an industrial machine. Immediate view|
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|Figure 3: Immediate postoperative view of defatted and adapted mesh autograft|
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|Figure 8: Postoperative 9th month motor function. Finger and wrist extension|
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|Figure 9: Postoperative 9th month motor function. Finger and wrist flexion|
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| Discussion|| |
Wide degloving injuries of the extremities are challenging to reconstruct due to the nature of the defect. Various methodologies have been described. The first thing that comes into mind may be adaptation of avulsed tissue directly; the current literature shows that in such cases, partial flap necrosis is frequent.
Microsurgery can be seen as another alternative to adapt the avulsed flap. Recent research comparing full-thickness skin grafts with arterialization of avulsed flap conducted by Waikakul, results show that reconstructing the defect that is in the early stage with the skin graft has much more effective results with less hospitalization. Authors state that, even though good results can be obtained by using revascularization, necrotic segments that cannot be arterialized even with an anastomosis need to be sacrificed and grafted for complete wound coverage. Reconstruction of the defective area with the flap is another option.,, Yet, donor site morbidity, possible infection of the reconstructed area, technical difficulties, and longer hospitalization rates are all limiting factors.
Donor site morbidity is a concern for full-thickness and split-thickness skin grafts harvesting. Full-thickness skin grafts provide a limited amount of harvest in a single procedure. While split-thickness skin grafts donor sites heal with secondary healing leading to conspicuous scar. Split-thickness grafts have secondary contraction as another limitation that can be problematic in the upper extremity.
During the reconstruction of the wide avulsion defects, direct adaptation or adaptation after meshing of the avulsed flap as a full thickness skin graft should be considered as the first option due to numerous causes. First and most important is preventing additional donor site morbidity. Besides providing an immediate reconstruction, this method also eliminates the risk of flap necrosis thus minimizes the need for revisional procedures. Given the substantial defect that makes the patient prone to nosocomial infections, reduced hospitalization period is favorable. Results are esthetically pleasing. There have been several studies in the literature claiming the use of avulsed flap as a full thickness skin graft after defatting is still the most practicable method for these injuries.,, Comparative studies have also found the technique beneficiary.
For avulsion injuries of the upper extremity, defatting and adaptation of skin flap as a graft is a reliable method of reconstruction that minimize additional morbidities.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]