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Case Report

Use of Avulsed Skin Flap as Donor Site for Reconstruction of

Total Forearm Skin Avulsion Injuries
Burkay Akduman, Galip Gencay Üstün, Koray Gürsoy, Uğur Koçer
Department of Plastic Reconstructive and Aesthetic Surgery, Ankara Training and Research Hospital, Altindag, Ankara, Turkey

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

Introduction After taking informed consent prior to treatment the patient

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.
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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 [Figures 4‑7]. Functional
capacity is fully preserved [Figures 8‑10].
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
Address for correspondence: Dr. Burkay Akduman,
Ankara Training and Research Hospital, Ulucanlar Cd. Ankara
Egitim Ve Arastirma Hastanesi, 06230 Altindag, Ankara, Turkey.
E‑mail: burkayakduman@yahoo.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com
How to cite this article: Akduman B, Üstün GG, Gürsoy K, Koçer 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.

DOI:
10.4103/tjps.tjps_97_18 Submission: 13-12-2018, Revision: 07-02-2019,
Acceptance: 05-03-2019, Publication: 26-09-2019.

© 2019 Turkish Journal of Plastic Surgery | Published by Wolters Kluwer - Medknow 211
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Akduman, et al.: Meshing of avulsed flap for grafting

Figure 1: Avulsion injury caused by an industrial machine. Immediate view Figure 2: After defatting of avulsed flap

Figure 3: Immediate postoperative view of defatted and adapted mesh autograft Figure 4: Dorsal view. Postoperative 9th month

Figure 6: Radial view. Postoperative 9th month

Figure 5: Volar view. Postoperative 9th month

Figure 8: Postoperative 9th month motor function. Finger and wrist

Figure 7: Ulnar view. Postoperative 9  month
th
extension

current literature shows that in such cases, partial flap necrosis Microsurgery can be seen as another alternative to adapt
is frequent.[1] the avulsed flap. Recent research comparing full‑thickness

212 Turkish Journal of Plastic Surgery ¦ Volume 27 ¦ Issue 4 ¦ October-December 2019

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Akduman, et al.: Meshing of avulsed flap for grafting
Figure 9: Postoperative 9th month motor function. Finger and wrist flexion
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.[3‑5] 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.[6‑8] 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.
Turkish Journal of Plastic Surgery ¦ Volume 27 ¦ Issue 4 ¦ October-December 2019
Figure 10: Postoperative 9th month elbow motor function
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
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