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      Successful repair of total hand degloving injury by avulsed skin in situ replantation through vascular transplantation: a case report

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          Abstract

          A 35-year-old man presenting with right-sided total hand skin degloving injury due to crushing of printing machine was reported in this study. The superficial vein of forearm was transplanted intraoperatively to reconstruct the blood supply, and the avulsed skin was replanted in situ. The patient was followed-up for 2 years, and satisfactory results and functional recovery were achieved.

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          Most cited references 11

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          Treatment of traumatic degloving injuries of the fingers and hand: introducing the "compartmented abdominal flap".

          Degloving injury of the hand and fingers is one of the most severe and debilitating hand injuries and an operation of choice is yet to be found. In this study, we introduce a modified abdominal flap, the "compartmented abdominal flap," for coverage of degloving injuries of the fingers and hand. The flaps reported up to now are diverse, and 2 or even 3 flaps in 1 session have been used to cover the hand and fingers. Often, the flaps used have mismatching colors and the donor defect is huge when 2 large flaps are used in 1 setting. In this study, we present a 1-flap solution to treat degloving injuries of the hand and fingers. The compartmented abdominal flap was used in 6 patients with different hand and/or finger degloving injuries, which were covered by a 1-flap procedure. The single flap is designed in 2 layers: the flap that is an abdominal flap is elevated as usual and at the next stage of dissection, we create a separate compartment for each finger in the superficial fatty layer of the skin flap making pockets that encircle each finger separately. An external fixator device is placed to hold the fingers in their respective pockets. The flap is severed in 3 to 4 weeks time in a serial manner. The volar surface of the fingers, which is covered by fatty tissues by then, is skin grafted at a later date. All the flaps survived and the contour of the hand and sensation was superior to the earlier flaps reported in the literature and in our earlier patients. The grasp and pinch function is better owing to the adherence of tissues to the volar surfaces of the fingers. The slippery feel of flaps over the volar surfaces of the fingers in handling objects is not felt or seen. The "compartmented abdominal flap" is a modification of the routine abdominal flap for degloving injury of the hand and fingers. The flap is designed in 2 layers: 1 layer is to cover the dorsum of the hand and the other is created in the fatty layer in separate compartments for each finger. At a later date and after flap separation, the raw volar surface is left to granulate and is then covered by a split thickness skin graft.
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            Replantation of degloved skin of the hand.

            The treatment of a degloving injury is one of the most difficult problems in hand surgery. Various reconstructive procedures have been adopted in the past years, all with poor results. Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by microsurgical replantation. The injury involved the thumb in three patients, the ring finger in three patients, the little finger in one patient, and multiple fingers in two patients. Successful complete revascularization was obtained in seven patients. In one case a superficial necrosis of the replanted thumb skin occurred with good preservation of the subcutaneous layer. In one patient with a degloving injury involving multiple fingers, revascularization was achieved only in the middle finger, and the first ray was secondarily resurfaced by a free flap from the foot. In our experience revascularization of the degloved skin does represent the best solution and must be managed as an emergency procedure. Coverage obtained in this way offers the best cosmetic result and allows early mobilization with good recovery of joint movement. Reestablishing sensibility is more difficult. It is not always possible to suture the nerves damaged by the trauma, and even when a careful primary nerve anastomosis is performed, the results often are unsatisfactory, probably because of the avulsive mechanism of nerve injury.
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              A new classification to aid the selection of revascularization techniques in major degloving injuries of the upper limb.

              Difficulties in management of major degloving injuries of the upper limb are compounded by their relative rarity and a lack of clarity in decision-making regarding surgical treatment strategies. Management options include salvaging the degloved segment through revascularization techniques such as direct arterial anastamosis or arterio-venous (AV) shunting, and reconstructing the unsalvageable degloving injury with microsurgical or non-microsurgical techniques. This article focuses on the use of revascularization techniques as a means to salvaging a major degloved segment. We propose a new classification to aid decision-making in strategies to salvage the degloved skin. This is based on assessment of the degloved segment regarding its suitability for revascularization, the choice of revascularization technique, and its anatomical expendability. Major degloving injuries involving the palm but not the digits is a strong indication for AV shunting in isolation (Group 1). Major degloving injuries that include the digits as well require both AV shunting and digital artery revascularization (Group 2). Major deglovings involving the dorsum of hand or forearm are only relative indications for AV shunting and traditional management with flap reconstruction or skin grafting is equally appropriate. This new classification and its application are discussed in a number of case examples.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2018
                17 August 2018
                : 14
                : 1429-1433
                Affiliations
                Department of Hand Surgery, Wuxi No 9 People’s Hospital Affiliated to Soochow University, Wuxi 214000, People’s Republic of China, wxswkyyryj@ 123456163.com
                Author notes
                Correspondence: Yongjun Rui, Department of Hand Surgery, Wuxi No 9 People’s Hospital Affiliated to Soochow University, Lixi Rd. 999, Wuxi 214000, People’s Republic of China, Email wxswkyyryj@ 123456163.com
                [*]

                These authors contributed equally to this work

                Article
                tcrm-14-1429
                10.2147/TCRM.S158812
                6103316
                © 2018 Wang et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Case Report

                Medicine

                surgical skills, hand skin degloving injury, microsurgery, vascular transplantation

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