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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 27  |  Issue : 4  |  Page : 211-213

Use of avulsed skin flap as donor site for reconstruction of total forearm skin avulsion injuries


Department of Plastic Reconstructive and Aesthetic Surgery, Ankara Training and Research Hospital, Altindag, Ankara, Turkey

Date of Submission13-Dec-2018
Date of Acceptance05-Mar-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Burkay Akduman
Ankara Training and Research Hospital, Ulucanlar Cd. Ankara Egitim Ve Arastirma Hastanesi, 06230 Altindag, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_97_18

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  Abstract 


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 12];27:211-3. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/211/267937




  Introduction Top


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 Top


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 2: After defatting of avulsed flap

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Figure 3: Immediate postoperative view of defatted and adapted mesh autograft

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Figure 4: Dorsal view. Postoperative 9th month

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Figure 5: Volar view. Postoperative 9th month

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Figure 6: Radial view. Postoperative 9th month

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Figure 7: Ulnar view. Postoperative 9th month

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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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Figure 10: Postoperative 9th month elbow motor function

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  Discussion Top


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.[1]

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,[2] 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.[3],[4],[5] 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.[6],[7],[8] Comparative studies have also found the technique beneficiary.[2]

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kudsk KA, Sheldon GF, Walton RL. Degloving injuries of the extremities and torso. J Trauma 1981;21:835-9.  Back to cited text no. 1
    
2.
Waikakul S. Revascularization of degloving injuries of the limbs. Injury 1997;28:271-4.  Back to cited text no. 2
    
3.
Graf P, Kalpen A, Biemer E. Revascularisation versus reconstruction of degloving injuries of the heel: Case report. Microsurgery 1995;16:149-54.  Back to cited text no. 3
    
4.
Lai CS, Tsai CC, Liao KB, Lin SD. The reverse lateral arm adipofascial flap for elbow coverage. Ann Plast Surg 1997;39:196-200.  Back to cited text no. 4
    
5.
Rautio J. Resurfacing and sensory recovery of the sole. Clin Plast Surg 1991;18:615-26.  Back to cited text no. 5
    
6.
Huemer GM, Schoeller T, Dunst KM, Rainer C. Management of a traumatically avulsed skin-flap on the dorsum of the foot. Arch Orthop Trauma Surg 2004;124:559-62.  Back to cited text no. 6
    
7.
Jeng SF, Hsieh CH, Kuo YR, Wei FC. Technical refinement in the management of circumferentially avulsed skin of the leg. Plast Reconstr Surg 2004;114:1225-7.  Back to cited text no. 7
    
8.
Lim H, Han DH, Lee IJ, Park MC. A simple strategy in avulsion flap injury: Prediction of flap viability using wood's lamp illumination and resurfacing with a full-thickness skin graft. Arch Plast Surg 2014;41:126-32.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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Case Report
Discussion
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