Application of Artificial Dermis Combined With a Medial Flap From the Second Toe to Repair Degloving Injury of the Fingertip.

There is no standard technique for repairing degloving injuries of the fingertip. Nail bed flap transplantation is a common surgical technique to address this injury, but this procedure inevitably damages the donor site in the toe. This article describes a surgical technique that can restore the appearance of the injured fingernail and preserve the length and function of the injured finger without damaging the toenail.

Integra® Dermal Regeneration Template as an alternative technique to treat degloving injury of fingers.

Soft tissue covering of degloving injuries of fingers remains a common challenge in trauma. In this case, we report the good long-term results after the use of Integra® Dermal Regeneration Template in combination with a split-thickness skin graft as an alternative treatment option for a patient with a traumatic degloving injury of multiple fingers.

Innervated Reconstruction of Fingertip Degloving Injury Using a Dorsal Digital Perforator Flap Combined With a Cross-Finger Flap.

BACKGROUND: The reconstruction of a fingertip degloving injury presents a functional and aesthetic challenge. We used a dorsal digital perforator flap combined with a cross-finger flap to reconstruct this type of injury. The purposes of this retrospective study were to evaluate the efficacy of the combined flaps and to present our clinical experience. METHODS: From November 2016 to October 2019, 16 patients (13 men and 3 women) with fingertip degloving injuries were treated with a dorsal digital perforator flap combined with a cross-finger flap for innervated reconstruction. We used an innervated dorsal digital perforator flap for the reconstruction of the dorsal defect of the degloved fingertip and an innervated cross-finger flap for the volar defect. The average size of the defect was 4.2 × 1.9 cm. The average sizes of the flaps were 2.3 × 2.1 cm (the dorsal digital perforator flap) and 2.5 × 2.1 cm (the cross-finger flap). RESULTS: All flaps and skin grafts survived completely without ischemia or venous congestion. All wounds and their donor sites healed primarily without exudation and infection. Patients were followed up for a mean time of 11.3 ± 1.9 months (range, 9-15 months). At the final follow-up, no significant difference was seen in the averaged total active motion between the injured fingers and the contralateral fingers. No significant difference was found in the averaged total active motion between the donor fingers and the contralateral fingers. All flaps obtained excellent or good sensory performance. All flaps had mild cold intolerance. Thirteen patients had no pain, 2 reported mild pain, and 1 experienced moderate pain. Ten patients were very satisfied with the appearance of the reconstructed finger. CONCLUSIONS: The dorsal digital perforator flap combined with a cross-finger flap is an effective and reliable method for the reconstruction of fingertip degloving injuries.

The triple conjoined scapular-latissimus dorsi-groin flap for reconstruction of long lower extremity degloving injury: A case report.

Since the introduction of the angiosome concept, many attempts have been made to push the dimensional limits of free tissue transfers. While initially limited by the boundaries of random vascularization of adjacent angiosomes, wider flaps were transferred by combining contiguous source vessels. Combined flaps, either chimeric or conjoined, represent nowadays the largest reconstructive options in the human body. This is the first report of a triple conjoined free flap with two vascular anastomoses, able to cover the anterior surface of the entire lower limb, representing the longest flap ever reported in history. A 43-year-old woman sustained a car accident as a pedestrian and presented with a massive circumferential degloving injury of the right lower limb. Femoral displaced shaft fracture and Gustilo type IIIb tibial fracture were diagnosed with emergent CT scan. A myocutaneous latissimus dorsi flap was planned, conjoined with the scapular flap to obtain a thick and large cover for the knee, and with a groin flap, to cover for the foot. Descending branch of lateral circumflex femoral artery and anterior tibial artery at the dorsum of the foot were selected as recipient vessels. Donor site was closed primarily. All flaps survived and no immediate nor late complications were reported. Follow up was 3 months. The triple conjoined flap can be considered a safe and useful reconstructive tool in severe degloving injuries of the lower limb, allowing the coverage of a large surface of the lesion with a single operation and without increasing the donor site morbidity.

Combined use of progressive tension suture and negative pressure wound therapy in large torso degloving wounds.

OBJECTIVE: To demonstrate the associated use of progressive tension sutures (PTS) with negative pressure wound therapy (NPWT) in large torso degloving wounds. METHODS: This is a case report of two patients with large torso degloving wounds caused by trauma, both of whom were treated with combined PTS and NPWT. Statistics related to wound treatment responses are presented. RESULTS: Initial wound area for Patient 1 was 2400cm2 and 900cm2 for Patient 2. Within 21 and 12 days, respectively, using the combined method, the following data were observed: wound reduction of 94% and 99%, respectively; a closing speed rate of 98cm2/day and 75cm2/day, respectively; and a closing percentage of 4.45% per day and 8.25% per day, respectively. CONCLUSION: The use of combined PTS and NPWT techniques may be useful in the treatment of traumatic degloving injuries, reducing the wound area and facilitating reconstruction.

The use of a caudal auricular axial pattern flap for repair of a degloving pinna wound in a dog.

A 3-year-old male neutered French bulldog was presented for an anatomical degloving injury of the left pinna following a conflict with a larger dog at a park. Approximately 2/3 of the dorsal skin was removed from the convex surface of the left pinna along with an irregular, full thickness injury on the lateral aspect of the pinna distal to the cutaneous marginal pouch. A caudal auricular axial pattern flap (CAAPF) was used to reconstruct the pinna. The flap healed with no noted necrosis over the long-term. Postoperative cellulitis was noted for approximately 3 mo. The dog was medically managed for bilateral otitis externa multiple times over the course of recovery. Long-term function and cosmesis at 1.5 y after surgery revealed adequate functional movement of the pinna and acceptable cosmesis. It is concluded that, rather than a pinnectomy, a CAAPF can be offered as a surgical option in dogs that have injuries localized to the pinna. Key clinical message: A CAAPF is an alternative to pinnectomy for reconstruction of the pinna after degloving injury and yields a functional and cosmetically acceptable outcome.

Utilisation d'un lambeau auriculaire caudal axial pour la réparation d'une plaie de dégantage du pavillon de l'oreille chez un chien. Un bouledogue français mâle castré âgé de 3 ans a été présenté pour une blessure anatomique par dégantage du pavillon gauche suite à un conflit avec un chien plus gros dans un parc. Environ les 2/3 de la peau dorsale ont été retirés de la surface convexe du pavillon gauche avec une lésion irrégulière de pleine épaisseur sur la face latérale du pavillon distal par rapport à la poche cutanée marginale. Un lambeau auriculaire caudal axial (CAAPF) a été utilisé pour reconstruire le pavillon. Le lambeau a cicatrisé sans nécrose notée à long terme. Une cellulite postopératoire a été notée pendant environ 3 mois. Le chien a été pris en charge médicalement pour une otite externe bilatérale à plusieurs reprises au cours de sa convalescence. La fonction à long terme et l'esthétique à 1,5 ans après la chirurgie ont révélé un mouvement fonctionnel adéquat du pavillon de l'oreille et une esthétique acceptable. Il est conclu que, plutôt qu'une pinnectomie, un CAAPF peut être proposé comme option chirurgicale chez les chiens qui ont des blessures localisées au pavillon.Message clinique clé :Un CAAPF est une alternative à la pinnectomie pour la reconstruction du pavillon après une blessure par dégantage et donne un résultat fonctionnel et esthétiquement acceptable.(Traduit par Dr Serge Messier).

Clinical decision model for the reconstruction of 175 cases of scalp avulsion/defect.

PURPOSE: It has been reported widely on various methods of repairing scalp avulsion/defect, including anastomotic vessels for total scalp avulsion and dermal grafts (skin grafting, latissimus dorsi or anterior serratus flap, "visor flap" repair.). The long-term retrospective study, however, with large sample size remains rare; and there is no report on decision-making tree for repairing emergency scalp avulsion/defects under critical conditions. METHODS: The decision-making model is provided for surgeons to design the scalp reconstruction based on the retrospective analysis of 175 cases of scalp avulsion/scalp defect. In this 10-year retrospective study, 175 cases of the repair of scalp avulsion and scalp defects in a single center were analyzed. The clinical decision model was generated based on representative cases. RESULTS: For patients with scalp avulsion/defects, a comprehensive examination and evaluation on systemic injury and complication should be conducted first for saving lives and reducing trauma effects. To make more reasonable clinical decisions, it is also required to determine the location, size, depth of scalp defect the injury area of cranial periosteum, injury of blood vessel or other adjacent organs, and whether the scalp can be reused. Meanwhile, it is necessary to evaluate whether the patient can tolerate long-term anastomotic vascular surgery according to the vital signs and physical status. CONCLUSION: The primary treatment goal is to decrease traumatic effects and save patient's life while repairing and reconstructing scalp avulsions and scalp defects. In addition, it is necessary to comprehensively consider the anatomical, functional and cosmetic characteristics of scalp, surgical equipment, team technical skillsets and patient's own pursuit to optimize a reasonable surgical solution.

Revascularization of a Circumferential Hand and Forearm Degloving Injury Using an Arteriovenous Shunt.

Major upper-extremity degloving injuries with distal dysvascularity are rare and challenging surgical problems. When these degloving injuries occur over nonexpendable regions, such as the glabrous skin of the palm and digits, revascularization or replantation may be the treatment of choice. Because the degloved skin flap is often separated in the suprafascial plane, direct arterial repair may be impossible. We present a rare case of circumferential degloving of the hand and forearm with distal dysvascularity, treated successfully with revascularization with arterial anastomosis, venous anastomosis, and arteriovenous shunt creation. The patient required reoperation for partial flap loss and ligation of the arteriovenous fistula. At final follow-up 16 months after the injuries, she showed independence in activities, reported good functional use of the hand, and worked full-time at her original occupation.

Reconstruction of a Large Traumatic Medial Cheek Defect Using an Anterior-Based Subcutaneous Cervicofacial Rotation Advancement Flap.

In this article, we describe reconstruction of a large left-side medial cheek defect in a 78-year-old woman using a cervicofacial rotation advancement flap. To our knowledge, this is the second case of reconstruction of a large traumatic medial cheek defect using an anterior-based subcutaneous cervicofacial rotation advancement flap that has ever been reported. We applied retention sutures at the level of the jawline and zygomatic eminence using 3-0 nonabsorbable sutures between the subcutaneous tissue of the flap and the periosteum. Despite the limitation of having partially injured adjacent tissue available for reconstruction, meticulous dissection together with skilled postoperative nursing care yielded a good aesthetic outcome in this case.

A peculiar case of Morel-Lavelle lesion of upper limb.

Morel-Lavallee lesions (MLL) are post-traumatic, closed internal degloving injuries that can result in severe complications if not diagnosed early. It is conventionally seen in cases of the high energy injuries of the pelvis and lower limb. The accumulation of extravasated blood, secondary to fracture and soft tissue damage may cause internal degloving injury, skin necrosis, soft tissue damage and acute osteomyelitis. We report here the clinical and radiological features in a 32-year-old male referred from the emergency department of a tertiary hospital who had sustained high energy motor vehicle accident. On examination, there was a fluctuant, mobile, non-tender subcutaneous mass over the distal arm with suspicion of internal degloving injury. Plain radiographs showed no fractures. Ultrasound showed a fluid collection with the presence of septations and echogenic debris within the collection. Extravasation was noted between subcutaneous tissue layer and fascia at the posterolateral aspect of the arm. Wound debridement under general anaesthesia was carried out. Intraoperative findings reported a significant amount of thick serous fluid with necrotic debris. Unhealthy skin and fat layers were debrided. Underlying muscles were found to be healthy. The results of the intraoperative fluid culture and sensitivity showed no growth. Negative pressure vacuum dressing was carried out. After five cycles of vacuum dressing, the wound showed signs of healing with an improved range of motion of the elbow. Orthopaedic surgeons need to be vigilant of the possibility of MLL in the upper limb as a differential diagnosis in the management of high energy trauma.

A Novel Muscle Transfer for Independent Digital Control of a Myoelectric Prosthesis: The Starfish Procedure.

Control of independent digital flexion and extension has remained an elusive goal in myoelectric prosthetics for upper extremity amputees. We first performed a cadaver study to determine the feasibility of transferring the interossei muscles for each digit to the dorsum of the hand without damaging the neurovascular pedicles. Once this capability was ensured, a clinical case was performed transferring the interossei of the middle and ring fingers to the dorsum of the hand where they could serve as a myoelectric signal for a partial hand amputee to allow individual digital control with a myoelectric prosthesis. Before surgery, it was impossible to detect an independent signal for each interossei; however, after the surgery, signals were reliably detected, which allowed these muscles to serve as myosites for finger flexion using a myoelectric prosthesis and move each digit independently. This concept of salvaging innervated and perfused muscles from an amputated part and transferring them into the more proximal and superficial portion of a salvaged limb has broad applications for improved myoelectric prosthetic control.

Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report.

Post-traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision-making approach. We report a case of a 41-year-old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP-L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4-month follow-up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6-month follow-up. A successful treatment of post-traumatic lymphedema can be performed by using the SCIP-L free flap for soft tissue reconstruction of critical lymphatic drainage areas.

Preferred Experience of Modifications to Emergency Surgical Treatment for Total Scalp Avulsion With Halo-Vest Head Ring and Quick Hair Removing.

BACKGROUND: Total scalp avulsion is a fairly rear but severe soft tissue injury. Even with microsurgical replantation, the survival rate is still low. In this study, the authors incorporated 2 main modifications (Halo-Vest head ring and quick hair removing) and assessed the surgical outcomes versus those of traditional replantation. METHODS:: Eighteen patients were included in the study who suffered from total scalp avulsion. After consideration of the outcomes from the first 7 patients, the authors modified our surgical procedures and introduced the use of Halo-Vest head ring and quick hair removing in the treatments for the rest 11 patients. The surgical outcomes with both approaches were observed and compared, including the operation time and incidence of scalp necrosis. RESULTS:: The mean debridement time was 3.5 hours in traditional treatment versus 1.68 hours in modified treatment. The mean operative time was 11.14 hours in traditional treatment versus 8.05 hours in modified treatment. After the replantation, in those 7 patients without modifications, there was 1 total scalp necrosis and 6 partial scalp necrosis. In those 11 patients with modifications, there was 1 total scalp necrosis and 1 suffered a partial scalp necrosis, while the scalp survived well in other 9 patients. Classical cases with modified or traditional methods were reported respectively. CONCLUSION: The application of Halo-Vest head ring and quick hair removing provides a reliable method to treat total scalp avulsion. It is safe, technically easy and worth being widely used in the clinical application.

The management of degloving injuries of the limb with full thickness skin grafting using vacuum sealing drainage or traditional compression dressing: A comparative cohort study.

BACKGROUND: Degloving injuries of the limb are severe and frequently underrated. Few researches are available comparing the results of reattachment of the degloved skin grafts with the vacuum sealing drainage technique and the traditional compression dressing method. In this study, we aimed to compare the treatment outcomes of these two approaches. METHODS: Eighty-three consecutive patients were treated for degloving injury of the limb. Based on the treatment approach, the patients were divided into vacuum sealing drainage group (VSD group, n = 55) and traditional compression dressing group (TCD group, n = 28). After reattachment, the degloved skin was secured with stitches and compressed with VSD or TCD. The outcomes were mainly assessed based on the percentage of skin graft take. RESULT: In VSD group, there were excellent results in 18, fair in 9 and poor in 28, respectively; In TCD group, there were excellent results in 11, fair in 10 and poor in 7, respectively. Statistically, no significant difference was found between two groups in terms of the category of excellent results. However, significant higher incidence of poor results with necrotic areas exceeding 50% was observed in the VSD group than that in the TCD group. In addition, although the duration of hospitalization in the VSD group was shorter than that in the TCD group, the medical supply costs and total costs were much higher than that of the TCD group. CONCLUSION: VSD and TCD are equally effective in the management of degloving injuries of the limb; however, VSD technique may potentially have a higher risk of poor results with increased hospital charges. The traditional approach still has its merits in clinical practice, especially in rural hospitals when VSD is not available or unaffordable.

Hidden degloving rotator cuff tears secondary to glenohumeral dislocation.

BACKGROUND: A rare form of rotator cuff tear (RCT) is observed secondary to glenohumeral dislocation, followed by immediate repositioning, as well as formation of scar tissue between tendons and tuberosities. Radiographic diagnosis of such "degloving" tears is problematic because they are obscured by scar tissue. We aimed to describe characteristics of degloving tears and report outcomes following their arthroscopic repair. METHODS: Among 67 patients who underwent arthroscopic repair of RCTs secondary to shoulder dislocation, we identified 8 patients (12%) (7 anterior dislocations and 1 posterior dislocation), aged 54.5 years (range, 38-61 years), with typical characteristics of degloving tears. Preoperative imaging revealed massive 2- or 3-tendon tears in all patients (6 with a ruptured or dislocated long head of the biceps), evaluated preoperatively and at greater than 2 years, using the absolute and age- and gender-adjusted Constant scores, Subjective Shoulder Value, and Simple Shoulder Test score. RESULTS: The absolute Constant score improved from 27 (range, 17-54) to 89 (range, 62-95). The age- and gender-adjusted Constant score improved from 31 (range, 24-57) to 97 (range, 83-100). The Simple Shoulder Test score improved from 2 (range, 0-4) to 12 (range, 9-12), while the Subjective Shoulder Value improved from 18 (range, 10-30) to 90 (range, 60-100). All patients were very satisfied (63%) or satisfied (37%). CONCLUSION: We have described a particular form of RCT secondary to glenohumeral dislocation, resulting in degloving of the rotator cuff, followed by repositioning of tendons. The formation of scar tissue can obscure tendon tears on ultrasound, in which case further imaging is recommended to ascertain the diagnosis and avoid therapeutic delays.

Complications After Scalp Suturing Posttraumatic Avulsion.

Scalp avulsion is a rare but severe trauma. Most cases of this injury happened as a result of hair entrapment in a high-speed rotating machine. Treatment of scalp avulsion can be challenging. Nowadays, microsurgical scalp replantation has become the treatment of choice. However, there are situations in which replantation or even usage of scalp as composite grafts is not possible. The aim of this paper is to present 2 cases of scalp avulsion, which needed split-thickness skin graft for covering posttraumatic scalp loss. Closing large scalp defects after its avulsion by skin graft is still a viable option, especially when replantation and even usage of scalp as a composite graft is not achievable. Scalp shaving is mandatory before any surgical procedures.

A Patient With Severe Lower Face Degloving Injury.

Avulsions of mandible are among the most devastating lesions observed in cranio-maxillofacial traumas. They present an important health problem because of the high risk of morbidity related to deformities that cause functional limitations and esthetic changes. The avulsions commonly result from high-energy effects, which cause complete or partial separation of the mandibular bone of the face. As a result of the intense aggression, the skin and subcutaneous tissues of the bone are usually removed, affecting muscles, fascia, blood vessels, and the surrounding nerves. This article aimed to present a case of partial avulsion of mandible caused by car accident. Here, we emphasize the importance of correctly performing patient stabilization and maintenance of the airways, damage control, and facial reconstruction. Finally, we proceeded with a literature review to discuss standard protocols and controversies in the treatment of these lesions.

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report.

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.

Partial medial second toe pulp free flap and dermal substitute with skin graft for salvage reconstruction of a complete skin envelope degloving of the small finger.

Skin envelope degloving of fingers are rare injuries that require rapid care and surgical treatment. Mostly caused by ring finger injuries, these traumas include bone, tendon and neurovascular pedicle damage. The authors present an unusual case of finger degloving limited exclusively to the skin envelope, without skeletal, tendinous or vascular lesion. This rare case of skin envelope degloving rendered microsurgical revascularization impossible. The authors report the results at 12 months following salvage reconstruction combining a partial second toe pulp free flap for the volar side and a dermal substitute with a thin skin graft for the dorsum.